COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX64121879 
RC261  .B872  Cancer  and  its  non-s 


RCZCf  B87Z 

Columbia  Stotoettfttp 

intljfCttpofitogork 

College  of  yiii'sinans  anb  ^urgrons 
Htbrarp 


G  i  p  t  op- 
UK.  Mar/  L HA. Snow 


,IX /~'* «- 


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CAN  (J  E"E 

AND  ITS 

NON-SUEGICAL  TREATMENT 


BY 

L.  DUNCAN  BULKLEY,  A.M.,  M.D. 

SENIOR    PHYSICIAN   TO    THE    NEW    YORK   SKIN   AND   CANCER   HOSPITAL 
MEMBER   OF   THE   AMERICAN   ASSOCIATION   TOR   CANCER   RESEARCH 


NEW  YORK 

WILLIAM  WOOD  AND  COMPANY 

MDCCCCXXI 


l^tix- 


COFYBIGHT,    1921 

Bt  WILLIAM  WOOD  AND  COMPANY 


IT  K     M  4  P  I,  11    J>  R  R  5  S     YORK    T  A. 


PREFACE 

An  attempt  has  been  made  in  the  following  pages  to  study 
cancer  from  all  its  angles  and  aspects,  except  that  of  operative 
surgery,  which  latter  has  been  exploited  heretofore,  quite  to  the 
exclusion  of  any  possible  medical  consideration  of  the  disease. 

It  has  been  a  difficult  task  to  compress  within  a  certain 
compass  sufficient  data,  and  to  make  each  chapter  satisfactorily 
full  and  clear,  so  that  all  would  be  understood.  For  the  amount 
which  has  been  written  concerning  cancer  in  books  and  period- 
icals is  so  enormous  that  the  process  has  entailed  an  amount  of 
reading  and  study  hardly  imaginable. 

As  will  be  seen,  the  work  of  Dr.  James  Ewing,  one  of  the  most 
competent  and  careful  pathological  scientists  living,  has  been 
drawn  on  very  largely,  along  certain  lines,  with  his  kind  personal 
permission.  It  was  not  intended  to  slight  the  views  of  other 
pathologists,  but  Dr.  Ewing's  masterly  work  on  neoplastic 
diseases  covered  the  pathological  ground  so  completely,  and 
presented  various  subjects  in  such  a  definite  and  seemingly 
conclusive  manner,  and  embraced  so  much  of  the  work  of  others, 
that  it  was  thought  best  to  adhere  largely  to  his  descriptions 
and  statements. 

It  was  not  considered  wise  or  necessary  to  attempt  any 
illustrations,  either  clinical  or  histological,  as  these  have  ap- 
peared so  abundantly  in  other  works  accessible  in  the  libraries. 

Nor  was  it  thought  desirable  to  dwell  too  long  on  the  various 
attempts  which  have  been  made  to  control  cancer  by  many 
different  means,  such  as  various  sera,  etc.,  or  the  theories  on 
which  their  employment  was  based.  Some  good  results  have 
been  claimed  from  many  of  them,  but  there  are  few  reliable  state- 
ments or  data  in  regard  to  end  results.  Also  no  attention  has 
been  paid  to  surgical  procedures,  except  an  analysis  of  the  end 
results,  as  far  as  could  be  obtained;  the  surgical  books  on 


iv  PREFACE 

cancer  which  were  consulted  amply  supply  all  needed  informa- 
tion as  to  details  and  technique  of  operations. 

The  aim  of  this  book  has  been  to  establish  on  firm  scientific 
grounds  the  proofs  of  the  constitutional  nature  of  cancer,  now 
so  widely  accepted,  and  to  illustrate  freely  the  value  of  this 
thesis  by  successful  cases. 

In  selecting  cases  for  report  the  effort  has  been  to  select  and 
present  them  in  such  a  manner  as  would  give  a  satisfactory 
presentation  of  the  disease  carcinosis,  as  it  sresults  or  products 
affect  various  portions  of  the  human  economy,  to  which  prod- 
ucts, or  local  manifestations,  the  name  of  cancer  is  usually 
given.  All  this  is  in  opposition  to  the  more  recent  views  as  to 
its  purely  local  nature,  and  to  the  idea  that  excision  or  removal 
in  any  way  of  the  local  lesions  of  the  disease  can  possibly  effect 
a  radical  cure  of  cancer,  which  experience,  sustained  by  mor- 
tality statistics,  has  shown  to  be  no  longer  tenable. 

The  comparison  is  constantly  made  between  tuberculosis  and 
cancer,  as  indicating  the  radical  difference  in  results  between 
an  intelligent  and  faithful  application  of  medical  principles 
and  treatment,  and  surgery,  in  handling  these  two  ormidable 
enemies  of  the  human  race;  for  the  mortality  of  the  former  has 
declined  about  thirty  per  cent  in  the  last  twenty  years,  under 
wise  medical  care,  while  that  of  cancer  has  risen  about  thirty 
per  cent,  in  the  same  period,  under  surgical  domination. 
While  no  absolute  statement  can  yet  be  made  statistically  as 
to  the  reduction  of  mortality  by  a  properly  directed  dietetic, 
hygienic,  and  medicinal  treatment  of  cancer,  the  clinical  portion 
of  this  work  furnishes  data  from  which  may  be  judged  some  of 
its  results.  It  is  confidently  asserted  that  when  the  principles 
and  practice  here  laid  down  are  fully  understood,  widely  accepted, 
and  generally  acted  upon,  there  will  be  shown  a  reduction  in  the 
mortality  of  cancer  which  will  be  conclusive  and  gratifying. 

I  would  like  to  repeat  what  I  have  said  in  my  former  books, 
and  elsewhere  in  this,  as  a  word  of  caution  in  regard  to  the 
medical  treatment  of  cancer.  Namely,  that  this  is  not  to  be 
entered    upon    lightly    or    without    due    consideration.     For, 


PREFACE  v 

although  when  rightly  carried  out  long  enough,  the  results 
obtained  far  exceed  any  that  can  be  otherwise  secured,  on  the 
other  hand  a  lax,  or  careless,  or  too  brief  employment  of  the 
measures  enjoined  can  only  end  in  disappointment.  It  takes  a 
great  deal  of  time,  patience,  and  careful  thought,  as  well  as 
resolute  will,  to  fully  succeed  along  this  line  of  practice.  Also 
such  a  perfect  acquaintance  with,  and  confidence  in  the  prin- 
ciples on  which  it  is  based,  as  will  beget  a  like  confidence  in  the 
patient  to  enable  one  to  pursue  the  tedious  treatment  sufficiently 
long  to  secure  the  result  desired. 

No  attempt  has  been  made  to  furnish  a  full  bibliography 
regarding  cancer,  which  would  be  so  enormous,  and  is  very  fully 
presented  in  other  writings  on  this  disease,  and  reference  is  only 
made,  as  far  as  possible,  in  the  form  of  footnotes,  to  the  matter 
actually  consulted.  In  securing  much  of  this  I  am  greatly 
indebted  to  my  former  associate,  Dr.  Edward  Preble,  whose 
references  I  have  worked  into  the  text. 

L.  Duncan  Bulkley,  M.D. 

io  East  6ist  St. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/canceritsnonsurgOObulk 


CONTENTS 

CHAPTER  I 


Nature  of  Cancer 


CHAPTER  II 

Frequency  and  Geographical  Distribution  of  Cancer 14 

CHAPTER  III 

Civilization  and  Cancer 28 

CHAPTER  IV 

HlSTO-PATHOLOGY   OF   CANCER 42 

CHAPTER  V 
Bio-chemistry  of  Cancer 71 

CHAPTER  VI 

Diagnosis  of  Cancer 86 

CHAPTER  VII 
Prognosis  of  Cancer     105 

CHAPTER  VIII 
Metastasis  of  Cancer 114 

CHAPTER  IX 
Malignancy  of  Cancer     126 

CHAPTER  X 
Metabolism  of  Cancer 137 

CHAPTER  XI 

Medical  Aspects  of  Cancer 160 

vii 


viii  CONTENTS 

CHAPTER  XII 

Nosology  and  Relations  of  Cancer 168 

CHAPTER  XIII 
Relation  of  Diet  to  Cancer 201 

CHAPTER  XIV 

Mortality  from  Cancer:  Analysis  of  Surgical  Statistics 222 

CHAPTER  XV 

X-ray  and  Radium  Treatment  of  Cancer     242 

CHAPTER  XVI 
Bio-therapy  of  Cancer      272 

CHAPTER  XVII 

Dietetic,  Hygienic,  and  Medical  Treatment  of  Cancer 299 

CHAPTER  XVIII 

Clinical  Considerations  and  Results.     Cases 334 

CHAPTER  XIX 
Conclusions 43 x 

Index 439 


CANCER 

CHAPTER  I 
NATURE  OF  CANCER 

Cancer,  with  its  cause  and  proper  treatment,  is  still  one  of  the 
greatest  problems  before  the  medical  profession.  No  disease 
has  in  late  years  received  more  attention  than  cancer,  and  con- 
cerning no  disease  has  there  been  more  diligent  search  to  find 
out  its  nature  and  cause,  and  yet  to  many  it  is  still  a  great 
mystery,  and  most  writers  both  recent  and  older,  say  that  we 
know  nothing  as  to  its  cause. 

Tuberculosis,  which  at  one  time  seemed  to  threaten  even  the 
existence  of  the  race,  with  its  constantly  rising  mortality  has 
sunk  into  relative  insignificance,  as  we  have  learned  its  true 
nature  and  conquered  some  of  the  causes  of  its  ravages,  and  re- 
duced its  mortality  about  30  per  cent  since  1900,  by  careful 
medical  treatment. 

Syphilis,  under  various  names,  forms,  and  aspects,  was  for- 
merly much  more  of  a  menace  than  now;  in  earlier  years  it 
caused  veritable  epidemics  but  is  now  well  understood  and 
controlled. 

Leprosy  is  less  of  a  terror  than  in  earlier  times,  since  it  has 
been  definitely  shown  not  to  be  contagious,  and  is  now  slowly 
diminishing  in  frequency. 

Small  pox  no  longer  rages,  and  yellow  fever  and  the  plague, 
and  hook  worm  disease,  have  been  hunted  down  and  largely 
controlled  by  scientific  study  and  the  application  of  proper  sani- 
tary and  medical  measures.  And  so  on,  as  to  malaria  and  many 
of  the  ills  which  afflict  mankind. 


2  CANCER 

But  cancer  has  held  its  own  and  has  even  increased  in  fre- 
quency in  civilized  countries,  until  now  it  looms  large  as  a 
national  or  even  universal  scourge:  it  has  been  estimated  to 
cause  the  death  of  half  a  million  of  persons  yearly,  among  the 
civilized  people  of  the  earth,  and  untold  misery  and  suffering 
to  many  times  this  number.  In  the  United  States  with  over 
80,000  deaths  from  the  disease  last  year,  the  mortality  has  risen 
nearly  30  per  cent,  about  the  same  proportion  as  the  death  rate 
of  tuberculosis  has  fallen. 

And  all  this  has  occurred  in  spite  of  the  earnest,  faithful, 
and  intelligent  labors  of  innumerable  research  workers,  the 
sacrifice  of  countless  animal  lives,  and  the  expenditure  of  vast 
sums  of  money,  together  with  the  best  endeavors  of  surgeons, 
more  skilled  than  ever  before  in  the  history  of  medicine. 

Much,  however,  has  already  been  established  by  scientific 
research,  but  still  more  earnest  thought,  observation,  and  en- 
deavor are  necessary  in  seeking  most  diligently  for  the 
nature  and  cause  of  cancer,  both  in  the  laboratory,  as  well 
as  clinically  in  practice;  for  there  must  be  some  cause  of  the 
disease  and  also  some  reason  for  its  steady  increase  in 
morbidity  and  mortality. 

But  it  is  never  to  be  forgotten  that  as  Pope  says:  "The 
proper  study  of  mankind  is  man,"  and  the  true  base  upon  which 
all  real  advance  as  to  the  nature,  treatment,  and  prevention  of 
the  malady  can  ever  rest  must  be  founded  upon  clinical  observa- 
tion, with  proper  laboratory  research,  on  cancer  as  it  appears  in 
the  human  being,  rather  than  on  animal  experimentation.  To 
effect  this  we  must  study  the  patient  in  all  relations  of  life,  his 
diet  and  mode  of  living,  the  constitution  and  class  of  subjects 
in  which  the  disease  is  most  apt  to  manifest  itself,  the  chemico- 
physiologic  actions  going  on  in  the  system,  etc.,  both  before  and 
during  the  existence  of  the  malady,  and  by  synthesis  and  deduc- 
tion understand  what  is  wrong  and  endeavor  to  correct  it.  As 
all  this  is  done  intelligently  and  faithfully  the  malignant  process 
is  seen  to  yield,  even  in  cases  more  or  less  advanced.  This  is  no 
easy  task,  and  great  patience  and  perseverance  on  the  part  of 


NATURE  OF  CANCER  3 

both  physician  and  patient  are  necessary,  as  in  the  case  of 
tuberculosis. 

To  understand  the  study  of  the  true  nature  of  cancer  it  is  well 
first  to  consider  what  scientific  laboratory  research  and  clinical 
observation  have  already  determined  negatively  and  positively 
in  regard  to  its  nature  and  character.  First  as  to  negative 
propositions. 

i.  Cancer  is  not  wholly  due  to  traumatic  causes;  although 
these  may  play  some  part  in  its  occurrence  in  certain  localities 
and  cases,  when  other  causes  exist,  as  in  syphilis,  tuberculosis, 
gout,  etc. 

2.  It  is  pretty  conclusively  decided  that  cancer  is  not  caused 
by  a  micro-organism  or  parasite;  although  various  forms  of  these 
have  been  seen  in  connection  with  the  disease,  but  none  have 
been  conclusively  shown  to  convey  it  to  another  living  being. 

3.  It  is  known  clinically  and  experimentally  that  cancer  is 
not  contagious.  Surgeons,  pathologists,  and  nurses  have  never 
contracted  the  disease  from  the  practice  of  their  profession,  nor 
can  human  cancer  be  conveyed  to  animals  by  inoculation. 

4.  Nor  is  it  hereditary  in  any  appreciable  degree,  as  Life 
Insurance  statistics  have  repeatedly  shown;  although  certain 
rare  instances  have  been  reported  where  such  seemed  to  be  the 
case  and  some  tendency  in  that  direction  has  been  demonstrated 
in  regard  to  tumors  in  certain  strains  of  mice. 

5.  Occupation  has  not  any  very  great  influence  on  the  occur- 
rence of  cancer;  although  it  has  been  claimed  to  be  more  frequent 
in  some  pursuits  than  in  others;  but  a  careful  study  of  these 
instances  shows  that  in  the  former  there  are  elements  which 
demonstrate  constitutional  causes,  which  we  shall  see  lead  up  to 
the  disease. 

6.  Cancer  is  not  altogether  a  disease  of  older  years;  although 
its  incidence  is  increased  with  advancing  age. 

7.  Cancer  does  not  especially  belong  to  or  effect  any  particular 
sex,  race  or  class  of  persons.  It  is,  however,  more  frequent  in 
females  than  in  males,  although  of  late  years  the  proportion  in 
the  latter  is  steadily  increasing. 


4  CANCER 

8.  Cancer  is  not  confined  to  any  climate,  location,  or  section 
of  the  earth,  but  has  been  observed  in  all  countries  and  climates, 
though  with  different  frequency  according  to  the  mode  of  life 
there. 

9.  It  is  thus  seen  that  no  single  or  definite  cause  of  cancer 
has  been  demonstrated,  in  spite  of  the  immense  amount  of 
laboratory  effort  which  has  been  expended  in  this  direction. 
Nor  is  it  at  all  likely  that  such  will  ever  be  found,  as  experi- 
mental and  other  investigations  have  covered  almost  every 
possible  line  of  research,  with  only  negative  results  as  to  any 
definite  cause. 

But  while  laboratory  and  other  investigations  have  not 
demonstrated  any  single  cause  of  cancer,  and  have  yielded  only 
negative  results,  they  have,  by  elimination,  cleared  the  way  for 
a  study  of  its  causes  along  other  lines,  which  are  bright  with 
promise.  They  have  established  certain  facts  which  confirm 
the  views  which  from  time  to  time  have  been  briefly  expressed 
by  surgeons  and  those  who  were  best  acquainted  with  cancer, 
and  which  are  daily  gaining  wider  acceptance.  These  are, 
that,  because  of  its  constant  recurrence  after  removal,  and  from 
the  failure  of  surgery  to  check  its  rising  mortality,  it  must  be 
of  a  constitutional  nature,  intimately  associated  with  dietary 
or  nutritional  elements,  with  greater  or  less  failure  of  some  of 
the  organs  relating  to  life  processes,  the  details  of  which  will 
appear  later.  These  positive  results  of  laboratory  investiga- 
tion are  encouraging. 

1.  We  know  now  that  the  local  mass,  which  we  call  cancer, 
represents  but  a  deviation  from  the  normal  life  and  action  of 
certain  ordinary  cells  of  the  body.  These  once  normal  cells,  for 
some  reason  difficult  to  understand,  take  on  an  abnormal  or 
morbid  action,  with  a  continued  tendency  to  a  malignancy 
which  invades  contiguous  tissues,  and  even  distant  parts,  and 
in  the  end  tends  to  destroy  life. 

2.  There  is  some  reason  to  believe  that  this  diseased  action 
often  first  takes  place  in  what  is  known  as  "embryonic 
rests,"  or  pre-natal,  wrongly  placed  tissue  elements.     But  these 


NATURE  OF  CANCER  5 

latter  are  shown  to  exist  in  every  individual  in  many  localities, 
and  few  of  them  ever  take  on  this  malignant  activity,  and  as  no 
adequate  explanation  has  been  determined  for  this  action,  this 
basis  of  malignity  is  not  now  generally  accepted.  Moreover, 
in  a  large  share  of  instances  no  such  connection  has  been 
observed  microscopically. 

3.  Microscopic  study  has  shown  that  there  is  a  certain  change 
in  the  polarity  of  cells  about  to  become  cancer-genetic,  with  an 
altered  relation  of  the  centresome  to  the  nucleus.  These 
changes  have  been  well  attributed  to  an  alteration  in  the  enzyme 
of  the  cell,  which  further  depends  upon  its  nutrition,  as 
influenced  by  faulty  metabolism  of  food  elements. 

4.  The  blood  in  advancing  cancer  has  repeatedly  been  shown 
to  exhibit  many  manifest  changes,  which  indicate  vital  alter- 
ations in  the  action  of  the  organs  which  form  blood,  and  so 
control  the  nutrition  of  the  body  and  its  cells. 

5.  The  exclusion  of  all  other  possible  causes  leads  us  naturally 
to  look  to  a  disordered  metabolism  as  a  cause  of  the  disturbed 
action  of  the  hitherto  normal  cells;  and  we  find  much  to  con- 
firm this  view  both  in  laboratory  studies  on  the  bio-chemistry  of 
cancer,  and  also  in  clinical  and  statistical  observations,  as  will 
be  studied  later. 

6.  Laboratory  and  clinical  evidence  demonstrate  that  the 
secretions  and  excretions  of  the  body,  both  in  early  and  late 
stages  of  cancer,  exhibit  departures  from  normal  which  deserve 
consideration.  Although  none  of  these  have  as  yet  been 
established  as  pathognomonic  of  cancer,  they  all  indicate 
metabolic  disturbances  which  influence  the  nutrition  of  the 
cellular  elements,  and  so  these  secretory  and  excretory  dis- 
turbances are  of  importance  in  connection  with  its  causation. 

7.  As  all  healthy  cells  of  the  body,  by  their  catabolism  and 
anabolism,  contribute  a  hormone  or  something  to  the  general 
circulation,  so  experimental  evidence  shows  that  the  cells  of 
the  cancer  mass  itself,  when  fully  developed,  secrete  a  hormone 
or  something  which  is  poisonous  to  animals,  and  which  probably 
hastens  the  lethal  progress  of  the  disease. 


6  CANCER 

8.  Repeated  laboratory  experiences  have  demonstrated,  in  a 
most  remarkable  manner,  the  absolute  controlling  effect  of  diet 
on  the  development  of  inoculated  cancer  in  mice  and  rats,  so 
that  the  process  was  inhibited  almost  entirely  by  vegetable 
feeding. 

All  of  these  points  will  be  elaborated  fully  in  the  following 
pages. 

It  is  thus  seen  that  as  laboratory  experiences  have  eliminated 
the  local  nature  of  cancer,  they  have  also,  in  a  measure,  estab- 
lished the  fact  that  there  are  medical  aspects  of  the  disease 
which  further  studies  will  show  to  be  of  the  utmost  importance. 
All  this  tends  to  demonstrate  the  constitutional  origin  of  cancer, 
that  is,  its  relation  to  or  dependence  upon  deranged  metabolism 
and  nutrition,  which  are  now  recognized  as  the  basis  of  many 
diseases  of  more  or  less  serious  character.  But  clinical  and 
statistical  studies  come  in  with  overwhelming  force  to  confirm 
the  correctness  of  the  position. 

i.  It  is  recognized  that  under  medical  neglect  the  mortality 
from  cancer  has  steadily  and  greatly  increased  in  the  United 
States,  in  late  years,  in  spite  of  the  prodigious  advances  of  surg- 
ical attempts  at  control  during  the  same  time.  This  is  also  true 
of  all  countries  from  which  we  have  any  accurate  statistics. 
We  know,  also,  that  tuberculosis,  as  a  result  of  careful  medical 
attention,  has  decreased  in  mortality  by  almost  as  great  a  per- 
centage as  cancer  has  increased.  The  same  is  reported  by  reli- 
able observers  all  over  the  civilized  world. 

2.  Any  number  of  observers,  in  many  lands,  have  recorded 
the  almost  total  absence  of  cancer  among  aborigines,  living  sim- 
ple lives,  largely  vegetarian.  They  have  also  shown  the  definite 
increase  of  the  disease,  and  of  its  mortality,  in  proportion  to 
the  adoption  by  natives  of  the  customs  and  diet  of  modern 
civilization. 

3.  This  increase  of  cancer  mortality  seems  to  depend  largely 
upon  the  altered  conditions  of  life  attending  advanced  civiliza- 
tion, particularly  along  the  lines  of  self  indulgence  in  eating  and 
drinking,  together  with  indolence. 


NATURE  OF  CANCER  7 

4.  Statistics  from  many  countries  show  that  a  per  capita 
increase  in  the  consumption  of  meat,  coffee,  and  alcoholic 
beverages,  appears  to  be  coincident  with  a  very  great  and  pro- 
portionately greater  augmentation  in  the  mortality  of  cancer. 

5.  Clinical  observation  has  time  and  again  shown  the  specific 
effect  of  nerve  strain  and  shock  in  the  development  of  cancer; 
and  there  seems  to  be  little  question  but  that  the  enormous  nerve 
strain  of  modern  life  is  an  element  of  importance  in  this  direc- 
tion, both  through  metabolic  disturbance  and  by  direct  action 
on  living  cells,  as  is  seen  in  other  diseased  conditions. 

6.  At  present  no  clear  demonstration  is  possible  of  the  direct 
method  by  which  errors  of  metabolism  effect  the  changes  in  cells 
to  which  we  give  the  name  malignant,  any  more  than  we  know 
how  other  alterations  in  the  body  are  produced;  such  as  arterial 
degeneration,  bone  changes,  obesity,  etc.,  which  are  recognized 
as  due  to  metabolic  derangement. 

7.  The  results  which  have  been  observed  in  connection  with 
the  starvation  of  cancer,  by  ligation  of  vessels,  illustrate  the 
relation  of  the  blood  supply  to  growing  cancer. 

8.  Finally,  the  repeated  observation  and  report  of  the  sponta- 
neous disappearance  of  cancer,  by  careful  and  competent  medi- 
cal men,  shows  that  conditions  of  the  system  may  arise  which  are 
antagonistic  to  malignant  growth,  even  when  it  has  begun  to 
take  place;  just  as  other  wrong  conditions  of  the  system  arose 
which  favored  the  aberrant  and  malignant  action  of  previously 
normal  cellSj  resulting  in  the  mass  which  we  call  cancer,  a 
product  of  previous  disordered  systemic  action. 

Having  stated  now  the  fundamental  propositions  upon  which 
the  thesis  of  the  constitutional  origin  and  nature  of  cancer  rests, 
which  will  be  more  fully  developed  in  later  chapters,  we  may 
briefly  consider  some  general  questions  relative  to  the  subject. 

First  it  may  be  remarked  that  our  studies  do  not  relate  to 
oncology  in  general,  but  only  to  the  two  main  groups  of  malig- 
nant neoplasms,  commonly  known  as  carcinoma  and  sarcoma: 
although  unquestionably  all  tumors,  of  which  Ewing,  gives  a  list 
of  over  twenty,  have  relations  to  nutrition,  which  even  Ewing 


8  CANCER 

recognizes.  In  our  consideration  also  the  ordinary  epithelioma 
of  the  skin  is  excluded,  although  carcinoma  is  likewise  an 
epithelial  degeneration,  but  mainly  of  glandular  epithelium. 

The  histology  of  the  two  will  be  considered  in  a  separate 
chapter. 

We  come  then  to  the  question  "What  is  the  real  nature  of 
cancer? " 

Alas!  All  scientific,  experimental  and  clinical  investigations 
have  failed  to  settle  the  question,  and  the  medical  profession  is 
still  divided  as  to  the  answer.  Pathologists  and  surgeons  still 
cling  to  a  local  origin  and  nature,  while  evidence  comes  from  all 
sides  of  the  acceptance  by  medical  men  of  a  constitutional 
nature  of  the  disease,  and  all  must  acknowledge  that  "all  evi- 
dence points  to  the  conclusion  that  cancer  is  to  be  considered  as 
a  pathological  disturbance  of  the  normal  cell  life  from  some 
unknown  cause" — this  last  phrase  is  repeated  almost  universally 
by  writers  on  cancer. 

It  would  carry  us  too  far  from  the  practical  side  of  our  sub- 
ject, even  if  we  were  at  all  able,  to  present  or  analyze  the  vast 
number  of  contributions  which  have  been  made  to  the  patho- 
logical histology  of  cancer,  and  the  changes  which  take  place 
in  the  transformation  of  normal  cells  into  those  of  malignant 
character:  the  amount  of  microscopic  work  which  has  been  done 
along  this  line  can  hardly  be  imagined  and  the  literature  relating 
to  it  is  enormous.    Some  of  it  will  be  presented  in  a  later  chapter. 

Ewing1  defines  carcinoma  as  "a  tumor  process  characterized 
by  atypical  and  destructive  proliferations  of  epithelium,"  and 
emphasizes  the  lawless  overgrowth  of  neoplastic  structures 
which  show  variable  but  pronounced  grades  of  anaplasia,  or  the 
alteration  in  cell  character  which  constitutes  malignancy.  He 
states  that  "in  some  cases  carcinoma  has  developed  after  exci- 
sion of  wholly  benign  fibro-adenoma,"  and  the  immense  number 
of  cases  of  recurrent  cancer  after  operations  shows  that  we  must 
look  further  than  surgery  if  we  wish  to  stay  the  progress  of  the 
formidable  disease. 

1  EwiNG,  "Neoplastic  Diseases."     Philadelphia,  1910,  p.  27. 


NATURE  OF  CANCER  q 

Leo  Loebx  has  recently  made  a  most  interesting  study  of  the 
causes  of  cancer,  which  is  full  of  evidence  and  suggestions 
looking  toward  an  acceptance  of  the  views  set  forth  in  these 
pages,  and  is  well  worthy  of  careful  consideration.  Although 
the  article  relates  largely  to  experimental  cancer  in  lower 
animals,  the  deductions  appearing  here  and  there  are  equally  or 
more  reasonably  applicable  to  cancer  in  human  subjects.  He 
says,  for  instance:  "  Thus  we  may  assume  that  abnormal  meta- 
bolic processes  or  other  conditions  which  retard  development  at 
a  certain  place,  and  at  a  critical  period  of  development,  may 
cause  embryonal  malformations,  teratomata,  or  mixed  tumors. " 
Again:  "'It  is  therefore  possible  that  while  in  the  majority  of 
cancers  repeated  stimulation  of  tissues  leads  to  a  long  continued 
or  even  perpetual  increase  in  the  intensity  of  those  metabolic 
processes  which  cause  cell  proliferation  and  cell  movements,  in 
certain  sarcomata  the  same  effect  is  produced  through  a  con- 
stantly acting  extraneous,  chemical  growth  stimulus,  supplied 
by  micro-organisms  and  not,  as  in  the  case  of  the  majority  of 
cancers  through  their  own  metabolism  of  the  cancer  cells." 

Later  on  he  says:  "The  basis  of  this  transformation  in  cell 
equilibrium  may  be  conceived  as  a  change  in  cell  metabolism, 
during  which  substances  are  produced  which  maintain  the 
alteration  in  cell  metabolism  on  which  the  acceleration  in 
growth  and  the  increase  in  motility  depend.  It  is  conceivable 
that  in  certain  cases  a  similar  constant  alteration  is  produced 
through  a  stimulus  reaching  the  cell  from  an  extraneous  source; 
a  micro-organism  might  perhaps  be  able  to  supply  such  a 
stimulus." 

We  shall  see  in  later  chapters  that  while  it  is  universally 
acceded  that  cancer  is  not  parasitic  or  conveyed  directly  by 
micro-organisms,  it  is  recognized  that  the  latter  produce  diseases 
in  the  system  by  virtue  of  their  bio-plastic  composition,  acting 
largely  as  a  foreign  protein  in  the  tissues,  as  will  appear  in  a 
subsequent  chapter,  which  concides  with  the  propositions  upon 
which  this  work  is  based.    It  is  interesting  to  find  pure  scientists, 

1Loeb,  Amer.  Jour.  Med.  Sci.,  June,  1920. 


io  CANCER 

formerly  advocates  of  the  purely  local  nature  of  cancer,  of 
late  referring  to  metabolism,  and  the  changes  produced  in  the 
tissues  by  perverted  nutrition. 

It  would  be  useless  to  attempt  to  present  the  many  theories 
which  have  been  advanced  relating  to  cellular  metaplasia,  or 
even  to  detail  all  the  more  or  less  accepted  facts  as  to  the  manner 
in  which  normal  cells  change  and  degenerate  into  those  of  a 
malignant  character:  but  some  of  the  principal  facts  may  be  of 
service  in  understanding  somewhat  of  the  mode  of  development 
of  malignant  tissue  from  that  which  has  been  normal. 

The  statement  of  Virchow,  "  Omnis  cellula  e  cellula,"  that  is, 
"  Where  a  cell  arises  there  a  cell  must  have  previously  existed, 
just  as  an  animal  can  spring  only  from  an  animal  and  a  plant 
from  a  plant,"  forms  the  basis  of  all  study  on  the  genesis  of 
cancer  and  all  tumor  formation.  Karyokinesis,  or  indirect 
nuclear  or  cell  division,  is  at  the  bottom  of  all  growth,  both 
normal  and  malignant,  and  the  two  classes  of  growth  differ 
only  in  their  methods  and  activity.  In  healthy  tissues  cell 
proliferation  proceeds  in  an  orderly  manner,  forming  homolo- 
gous structures,  as  when  the  hairs  and  nails  are  constantly 
produced  from  newly  formed  cells  at  the  root,  and  the  result 
of  this  new-growth  is  removed  mechanically,  as  they  are  cut 
from  time  to  time. 

In  the  case  of  the  skin,  the  epidermal  layers  are  pushed 
forward,  and  finally  exfoliated  as  useless  epithelial  debris. 

With  the  cells  composing  other,  or  internal  structures,  how- 
ever, the  process  is  different.  For  here,  while  each  normal  cell 
produces  others  of  homologous  structure,  and  the  different  parts 
of  the  system  are  kept  in  active  service,  through  anabolism, 
the  older  or  effete  cells  are  removed  by  catabolism;  the  elements 
of  which  they  are  composed  are  thus  split  up  into  their  compo- 
nent parts,  and  carried  off  by  the  blood  or  lymph-stream,  and 
are  then  either  discharged  as  effete  substances  or  reutilized  in 
the  system  along  physiological  lines. 

But  the  process  relating  to  malignant  formation,  as  in  cancer, 
is  again  different.     We  have  seen  that  the  cells  in  this  disease 


NATURE  OF  CANCER  II 

have  lost  their  controlling  influence,  and  no  longer  tend  to  an 
homologous  action  leading  to  the  formation  of  new  normal 
tissue,  but  have  taken  a  heterologous  course,  wild  and  unre- 
strained, and  serve  no  useful  purpose  in  the  organism,  but  in  the 
end  lead  to  their  own  destruction  and  that  of  the  individual. 
In  other  words,  while  the  ordinary,  healthy  body  cells  of  the 
economy  all  have  their  functions  to  perform,  such  as  those  of  a 
contracting  muscle  or  a  secreting  gland,  the  cancer  cell,  having 
broken  away  from  its  accustomed  control,  expends  all  its  ener- 
gies simply  on  growth,  which  soon  becomes  over-growth  with 
all  its  well-known  evil  results. 

A  great  deal  of  thought,  study  and  speculation  have  been 
given  in  regard  to  the  behaviour  of  the  cells  themselves,  and 
strong  arguments  are  adduced  for  a  local  pathology,  that  is,  to 
regarding  the  cells  as  autonomous  beings,  possessed  of  morpho- 
logical and  physiological  independence. 

But,  on  the  other  hand,  we  must  recognize  that  there  is  some 
restraining  influence  which  causes  the  great  mass  of  cells  to 
reproduce  those  of  homologous  structure  into  useful  tissues, 
in  an  orderly  manner,  and  only  very  rarely  some  of  them  to 
break  loose  and  form  tumors  which  may  become  malignant  and 
even  destroy  life.  How  this  restraining  influence  is  modified 
or  lost  is,  of  course,  a  part  of  the  problem  of  cancer.  Those 
who  maintain  their  autogenous  character  lay  great  stress  on  the 
polarity  of  the  cells,  and  the  relation  of  the  centrosome  to  the 
nucleus,  indicating  a  change  in  the  polar  axis  in  cells  about  to 
become  cancer-genetic,  as  does  Ewing,1  in  his  recent  classical 
study  of  pre-cancerous  lesions.  But  whatever  changes  are 
observed  microscopically  we  must  recognize  that  the  cells 
themselves  must  be  influenced  ultimately  by  that  mysterious 
force  which  we  call  life,  which  ends  with  its  extinction  from  the 
body  as  a  whole,  and  which  is  eventually  related  to  nerve 
action.  We  must  also  recognize  that  the  cells  everywhere 
depend  for  their  life  and  activity  upon  the  blood  in  which  they 
are  bathed,  and  from  whence  they  draw  their  sustenance;  and 
1  Ewing,  Medical  Record,  1914,  Lxxxvi,  p.  951. 


12  CANCER 

this  blood  is  renewed  day  by  day  from  the  food  and  drink 
taken. 

Students   of   cancer   are   more   and   more   recognizing   and 
acknowledging  that  "all  these  phenomena,  apparently  so  dif- 
ferent, are  merely  protean  manifestations  of  one  common  proc- 
ess which  underlies  and  is  the  cause  of  them  all,  to  wit,  cell 
growth  and  proliferation."     The  particular  outcome  of  the  proc- 
ess in  any  given  case  is  due  to  the  influence  of  conditions  of 
nutrition — understanding  by  this  term  the  whole  of  the  material 
changes  wrought  in  the  organism  through  its  relations  with  the 
surrounding  world.     This  being  so  it  is  easy  to  understand  how, 
under  favorable  conditions,  certain  cells  may  take  an  independ- 
ent action,  growing  and  multiplying  without  regard  to  the 
requirements  of  adjacent  tissues  and  of  the  organism  as  a  whole. 
Nels  Quevli1  has  written  a  remarkable  and  most  interesting 
book,  showing  the  intelligence  of  the  cells  of  plants  and  animals 
in  building  up  various  structures,  and  while  not  devoted  to 
pathological  states,  explains  in  a  measure  how  cells  once  starting 
on  a  wild,  unrestrained,  heterologous,  and  destructive  course  can 
go  on  propagating  and  influencing  others  to  join  with  them. 
What  the  cause  is  which  induces  one  or  more  cells  to  begin  this 
course  of  morbid  action  is  as  yet  undetermined,  but  it  appears 
that  irritation,  whether  mechanical  or  chemical,  is  the  most 
likely  incentive  to  this  first  departure  from  normal  life. 

In  the  case  of  sarcoma  mechanical  injury  is  most  commonly 
seen,  and  in  cancer  of  the  breast  many  believe  that  a  blow  first 
excites  the  process.  In  deeper  structures  this  is  commonly  not 
recognizable,  nor  so  likely,  and  chemical  or  nutritional  irritants 
probably  start  the  process,  in  one  otherwise  prepared  for  it. 

There  seems  to  be  some  reason  to  support  the  view  advocated 
by  Williams,2  that  tumor  formation  and  growth  are  but  forms 
of  agamogenesis,  or  non-sexual  reproduction  of  cells,  distinctly 
related  to  the  decline  in  growth  of  the  body  in  general.     Hence 

1  Nels  Quevli,  "Cell  Intelligence,  etc."  The  Colwell  Press,  Minneapolis, 
ion- 

2  Williams,  "The  Natural  History  of  Cancer."  New  York,  1908. 


NATURE  OF  CANCER  13 

while  the  forces  of  growth,  development,  and  reproduction  are 
in  greatest  activity,  the  tendency  to  this  disease  is  relatively 
small;  but  when  growth  declines  and  nutrition  is  relatively  low 
the  cells  undergo  gemmation,  owing  to  perverted  nutriment, 
and  thus  hyperplasia  and  not  inflammation  is  the  starting  point 
of  every  neoplasm.  The  histology  and  chemistry  of  cancer 
will  be  considered  in  later  chapters. 

The  essence  of  our  study  thus  far  has  been  that  in  every 
instance  what  is  called  malignant  disease  is  but  an  aberrant 
action  of  originally  normal  body  cells.  That,  as  normal  cells 
find  their  nutriment  in  the  circulating  blood,  so  some  pathologi- 
cal change  in  this  latter  causes  them  to  take  on  an  abnormal 
action,  and  they  no  longer  develop  homologous  cells,  capable 
of  forming  normal  tissue,  but  heterologous  elements  which  have 
a  natural  tendency  to  break  down  and  exert  a  destructive  influ- 
ence on  adjoining  cells  of  any  kind;  and  in  this  process  they 
secrete  a  hormone,  or  substance,  which  is  prejudicial  to  the 
system  and  tends  to  destroy  life. 

Thus  it  is  seen  that  the  disease  under  consideration  is  not  a 
mysterious  something  from  without,  of  whose  cause  we  know 
nothing;  for  it  is  not  parasitic  or  contagious,  but  it  is  simply  a 
perverted  operation  of  internal  organs,  including  the  endocrin- 
ous glands,  whose  product,  variously  manifested,  we  call  cancer. 
We  all  recognize  such  an  explanation  for  many  diseased  condi- 
tions, such  as  gout,  arteriosclerosis,  rickets,  osteo-malacia, 
obesity,  etc.,  but  are  slow  in  acknowledging  the  internal  derange- 
ments which  lead  up  to  the  disease  we  are  studying.  It  is 
interesting  to  note  that  the  founders  of  the  index  catalogue  of 
the  Government  Library  placed  cancer  among  metabolic  dis- 
eases, where  it  still  stands,  and  also  that  in  the  very  recent 
"Loose-leafed  Living  Medicine"  published  by  Nelson,  it  is 
still  placed  there,  with  gout,  diabetes,  etc. 


CHAPTER  II 

FREQUENCY  AND  GEOGRAPHICAL  DISTRIBUTION 
OF  CANCER 

Cancer  in  man  has  been  observed  in  all  portions  of  the  globe, 
but  in  greatly  different  degrees  of  frequency,  according  to 
varying  conditions  of  life.  Growths,  benign  and  malignant, 
occur  also  in  animals,  birds,  and  fishes,  though  also  with  greatly 
varying  frequency  under  different  conditions,  the  frequency 
being  particularly  increased  by  domestication;  tumors  are, 
however,  rarely  found  in  mollusks,  reptiles,  or  amphibians, 
living  their  normal  life. 

Considerable  interest  has  been  excited  by  the  study  of  tumors 
occasionally  found  in  vegetable  oragnisms,  presenting  increased 
growth  and  proliferation  of  cells,  and  some  have  endeavored  to 
show  that  they  are  related  to  cancer  as  occurring  in  the  human 
being.1  Some  of  these  are  quite  local  and  benign,  as  galls,  due 
to  the  operation  of  insects,  or  of  cryptogamic  origin,  some 
remain  quite  local  and  relatively  benign,  others  extend  and 
spread  and  affect  the  health  and  life  of  the  plant.  But  no  suffi- 
cient proof  has  ever  been  produced  to  show  that  they  have  any 
real  relation  to  human  cancer. 

There  are,  however,  other  tumors,  especially  on  trees,  which 
do  afford  interesting  analogies  to  the  growth  of  benign  and  malig- 
nant tumors  in  man,  but  present  no  evidence  of  any  true  connec- 
tion; of  these  Williams2  has  made  a  most  interesting  study.  He 
shows  that  such  are  derived  from  abnormally  evolving  buds,  and 
remarks:  "  Thus  the  origin  of  buds,  as  well  as  their  subsequent 
development,  is  chiefly  determined  by  the  conditions  of  nutri- 
tion.    Whenever  there  is  excess  of  nutritive  materials,  capable 

1  Erwin  V.  Smith,  U.  S.  Department  of  Agriculture,  Bureau  of  Plant  Industry. 
Bulletin  No.  255,  191 2. 

2  Williams,  "The  Natural  History  of  Cancer."     New  York,  1908,  pp.  115-128. 


DISTRIBUTION  OF  CANCER  15 

of  being  utilized  for  growth  by  the  cells  of  the  part,  there  buds 
arise;"  and  many  of  the  specimens  of  abnormal  growths,  or 
excrescences,  which  he  observed  occurred  on  trees  situated 
where  their  roots  rested  in  soil  highly  charged  with  sewage 
matter.  While  all  these  studies  confirm  in  a  measure  what  may 
be  observed  in  human  cancer,  they  do  not,  of  course,  establish 
any  true  relationship  between  tumors  in  vegetable  organisms 
and  carcinoma  in  man;  they  only  show  that  where  there  is  cell 
life,  in  the  animal  or  vegetable  kingdom,  there  are  agencies 
which  can  cause  cells  to  proliferate  unwisely  and  uselessly,  if 
not  harmfully,  under  conditions  which  careful  observation  and 
study  can  recognize  and  overcome. 

Cancer  has  been  styled  a  disease  of  civilization,  like  tuber- 
culosis, although  of  quite  a  different  nature,  which  relationship 
will  be  considered  in  the  next  chapter.  Interesting  studies 
have  been  repeatedly  made  in  regard  to  the  increased  death  rate 
from  the  former,  in  England,  coincident  with  a  diminished 
mortality  of  the  latter,  in  accordance  with  nutritional  changes 
which  have  taken  place  in  certain  populations,  and  the  same 
has  occurred  in  the  United  States,  as  mentioned  in  the  previous 
chapter. 

Williams,1  who  quotes  largely  from  the  accurate  statistics 
which  have  long  been  carefully  recorded  in  England,  states  that: 
"While  tubercle  has  declined  with  great  rapidity,  cancer  has 
increased  at  a  still  faster  rate,  and  these  inversely  related 
changes  are  still  in  active  progress.  In  illustration  of  these 
remarks  it  may  be  mentioned  that  during  the  last  half  of  the 
nineteenth  century  the  cancer  mortality  for  England  tripled; 
while  during  the  same  period  the  tubercle  death  rate  declined  to 
the  extent  of  nearly  one-half.  Unless  some  great  change  in  the 
national  health  takes  place,  of  which  there  is  at  present  no  well 
marked  indication,  cancer  will  ere  long  claim  more  victims  than 
phthisis,  as  is  already  the  case  in  many  localities — e.g.  Hamp- 
stead,  Clifton,  Bath,  etc."  In  New  York  City  the  actual  num- 
ber of  deaths  from  cancer,  as  reported  by  the  Board  of  Health, 

1  Williams,  loc.  cit.,  p.  58. 


16  CANCER 

exceeded  those  from  tuberculosis  during  certain  five  weeks  in 
1920,  and  during  the  last  six  months  of  the  year  there  were 
actually  22  more  deaths  recorded  from  cancer  than  from 
tuberculosis.1 

All  statistics  from  various  localities,  show  that  cancer  has 
certainly  increased  in  mortality  very  greatly  of  late  years,  and 
in  the  United  States  the  rate  has  kept  pace  with  and  steadily 
exceeded  that  from  kidney  disease,  heart  disease,  and  apoplexy, 
which  are  recognized  not  as  local  diseases  but  of  internal  origin. 
Some  have  attempted  to  claim  that  this  increase  is  only  appar- 
ent, and  is  due  to  greater  accuracy  in  diagnosis,  and  the  pro- 
longing of  more  lives  to  an  age  when  cancer  is  more  common,  but 
there  is  no  doubt  in  the  minds  of  those  who  have  studied  the 
figures  of  the  Mortality  Tables  of  the  United  States  Census 
Bureau  that  the  increase  is  certainly  very  real;  and  unless 
measures  other  than  those  thus  far  employed  are  more  univer- 
sally adopted  the  death  rate  at  the  end  of  the  century  will  be 
appalling. 

It  is  impossible  even  to  give  a  comprehensive  idea  of  the  im- 
mense amount  of  work  which  has  been  given  to  the  study  of  the 
statistics  of  cancer  in  various  parts  of  the  world,  as  collected  in 
the  remarkable  works  of  Williams,  Jacob  Wolff2  and  F.L.  Hoff- 
man,3 from  which  I  shall  quote  freely,  as  also  from  others;  a 
synopsis  of  some  of  the  recorded  facts  and  figures  may  be  given 
in  order  to  properly  understand  our  subject. 

England  and  Wales  present  the  most  satisfactory  field  for  the 
study  of  the  progress  of  cancer,  as  the  national  vital  statistics 
have  been  remarkably  well  kept  since  1840:  even  at  that  time, 
under  the  able  direction  of  Wrilliam  Farr,  they  had  already 
acquired  a  well  deserved  reputation  for  reliability,  as  Williams 
remarks. 

In  that  year,  1840,  there  died  of  malignant  disease  in  England 
and  WTales,  1  in  5,646  of  the  total  population,  1  in  129  of  the 

1  Bulkley,  Medical  Record,  New  York,  January  29,  1921. 

2  Jabob  Wolff,  "Lehre  von  der  Krebs  Krankheit."     Jena,  191 1. 

3  F.  L.  Hoffman,  "The  Mortality  from  Cancer  throughout  the  World." 
Newark,  191 5. 


1900      1901      1902     1903     190- 

290 


1900     1901      1902      1903     19 


The  Death  I 
steadily  since  1900. 
due  to  the  effect  of 
inactivity  and  nerve 


DEATH  RATE  PER  100,000  POPULATION 

FROM  THE  UNITED  STATES  MORTALITY 
STATISTICS  FOR  1919 


1900  1901   1902  16 


1905   1906  1907   19 


1910  1911   1912  1913  1914  1915  1916  1917  1918  1919 


s£ 


XT 


V 


.^* 


1900     1901      1902     1903     1904     1905     1906     1907     1908     1909     1910     1911      1912     1913     1914     1915     1916     1917     1918     1919 


The  Death  Rates  from  Organic  Heart  Disease,  Nephritis,  Apoplexy  and  Cancer  have  all  risen 
steadily  since  1900.  If  we  accept  the  fact  that  the  increasing  Death  Rate  of  the  first  three  is  largely 
due  to  the  effect  of  Modern  Civilization,  especially  from  erroneous  eating  and  drinking,  with  bodily 
inactivity  and  nerve  strain,  it  is  reasonable  to  suppose  that  Cancer  is  due  to  the  same  causes. 


DISTRIBUTION  OF  CANCER  17 

total  mortality,  or  177  per  million  living.  In  1905  the  deaths 
due  to  this  cause  were  1  in  1,131  of  the  total  population,  1  in  17 
of  the  total  mortality,  or  885  per  million  living:  thus,  while  the 
population  has  only  a  little  more  than  doubled,  the  cancer 
death  rate  million  had  increased  five-fold. 

Objections  have  been  constantly  raised  that  this  alleged 
increase  in  the  mortality  from  cancer  is  not  real,  but  may  be 
accounted  for  on  these  grounds :  1 .  Mere  increase  of  population ; 
2.  The  average  age  of  the  population  having  advanced,  giving 
more  persons  of  a  cancer  age;  and  3.  Improved  diagnosis  and 
more  careful  death  certification.  As  these  are  vital  questions, 
which  are  often  brought  forward,  and  almost  always  mentioned 
when  I  have  spoken  before  many  medical  audiences,  I  will  give 
as  briefly  as  possible  the  conclusive  evidences  to  the  contrary, 
which  Williams  has  presented  by  figures  and  tables  in  many 
pages  of  his  instructive  book;  this  proof  will  apply  also  to 
references  which  will  be  made  regarding  the  increased  mortality 
from  cancer  in  other  countries.     I  will  quote  from  Williams. 

1.  Increasing  Population. — This  has  already  been  answered 
by  the  figures  already  given. 

2 .  Increase  of  A  verage  Longevity,  Giving  more  Persons  of  a  Cancer 
Age. — To  this  it  may  be  answered.  "The  saving  of  life  in 
modern  times  has  been  mainly  confined  to  the  pre-cancerous 
years  of  existence,  the  death  rate  of  males  over  35  and  of  females 
over  45  has  remained  almost  stationary,  while  the  numbers 
attaining  old  age  have  decreased.  Hence  only  an  infinitesimal 
fraction  of  the  increased  cancer  mortality  can  be  thus  accounted 
for.  Moreover,  an  increase  in  the  cancer  mortality  is  by  no 
means  a  necessary  corollary  of  the  survival  of  augmented  num- 
bers to  the  cancer  age,  as  the  Irish  mortality  statistics  show." 

3.  Improved  Diagnosis  and  more  Careful  Death  Certification. 
"If  improved  diagnosis  and  death  certification  have  caused 
additions  to  the  cancer  total — which  I  do  not  deny — the  same 
conditions  have  also  caused  subtractions  from  it.  Thus,  as  the 
Registrar  General  tells  us  in  his  fifty-fifth  Report,  that  even 
up  to  the  year  1880,  such  common  diseases  as  "fibroid  tumor, 


i8 


CANCER 


polypus,  and  lupus"  were  usually  classed  as  cancer.  In  like 
manner  many  other  morbid  states,  formerly  classed  as  cancer- 
ous, are  now  relegated  to  other  categories:  "  the  basis  of  this 
claim  is  also  easily  refuted  by  statistics  from  many  countries. 

Williams1  has  given  some  interesting  tables  showing  that  the 
increase  in  the  cancer  death  in  England  has  not  been  largely  due 
to  the  improved  diagnosis  or  registration  of  the  disease  in 
"inaccessible  regions,"  one  of  which  may  be  presented: 


Males  per  ioo  deaths  from 
malignant  disease 


Females  per  ioo  deaths  from 
malignant  disease 


1897 


1900 


1897 


1900 


Stomach 

Liver 

Rectum 

Tongue  and  mouth. . 
Intestine  (ex  rectum) 

(Esophagus  

Bladder 

Jaws 

Neck 

Pharynx,  tonsils,  etc. 
Larynx  and  trachea. 
Testis  and  penis 

All  others 


20.6 
14.2 
8.6 
6-3 
6-3 
5-7 
3-3 
3° 
2.7 

2-3 

1.8 
1-5 


76.3 
23 -7 


20.5 

13-9 
9.0 
6.8 
7.0 

5-4 
2.8 

2-3 
2-3 
2.2 
2.0 

i-5 


75-7 
24-3 


Uterus 

Breast 

Stomach 

Liver 

Rectum 

Intestine  (ex  rectum). 

Ovary 

(Esophagus  

Tongue  and  mouth. . . 

Bladder 

Jaws 

Neck 

All  others 


23 -5 

155 

n-3 

13.2 

5-2 

5-2 

i-7 

1.4 

1-3 

0.8 
0.6 
0.6 


82.3 

17.7 


22.5 

15-8 

138 

14-3 

5-2 

5-7 

1-7 

i-3 

0.6 

0.9 

0.6 

0.5 


82.9 
17. 1 


Hoffman2  has  given  an  interesting  table  showing  the  Cancer 
Mortality  from  the  records  of  the  Prudential  Insurance  Co.  of 
America  from  1891  to  191 3.  While  the  deaths  from  cancer  in 
1 891  formed  3  per  cent  of  the  total  mortality  in  1891,  it  had 
risen  steadily  to  6.1  per  cent  of  all  deaths  in  191 3. 

1  Williams,  loc.  cil.,  p.  55. 
!HoFFiiAN,  loc.  cit.,  p.  321. 


DISTRIBUTION  OF  CANCER 


19 


In  the  United  States,  however,  there  appears  to  have  been 
some  increase  in  the  deaths  from  cancer  affecting  "inaccessible 
regions"  as  shown  in  the  following  table: 


Deaths  from  Cancer 

in  Relation  to  Sex 

Location 

1911 

1912 

1913 

1914 

I9IS 

1916 

1917 

In- 
crease 

D         ,                       /  Male 

Buccal  cavity \  _        , 

I  Female... 

1 ,402 
32s 

1,46s 
373 

1,628 
338 

1,878 
392 

1,738 
385 

1,730 
36l 

1,846 
356 

404 
31 

8,698 

9,215 

9,749 

10, 122 

10,915 

11,481 

n.384 

2,686 

1  Female . . . 

8,667 

9,302 

10,018 

9,767 

10,306 

10,999 

11 ,140 

2,473 

2,464 

2,459 

2,811 

2,903 

3,156 

3,286 

3,4i6 

952 

intestines.               \  Female. . . 

3,36o 

3,464 

3,814 

3,842 

4,176 

4,430 

4,508 

1,148 

6,707 

7,089 

7,706 

8,152 

8,120 

8,898 

8,464 

1,757 

74 

75 

78 

88 

64 

97 

84 

10 

1  Female . . . 

4,190 

4.356 

4.514 

5,335 

5,099 

5,46i 

5,338 

1,148 

„,  .                              J  Male 

Skin <  _        , 

1  female. . . 

1 ,011 

1,079 

1,128 

1 ,242 

1,221 

1,294 

1,373 

362 

608 

664 

597 

715 

734 

768 

740 

132 

n..                             /Male 

Other  organs <  _ 

[  Female. . . 

3,876 
2,646 

4,171 
2,819 

4,651 
2,896 

5,049 
2,935 

5,424 
3,246 

6,156 
3,659 

6,395 
3.57S 

2,519 

933 

But  wherever  the  increase  in  mortality  may  occur,  in 
internal  or  external  cancer,  it  only  shows  the  unfortunate 
results  of  the  past  and  even  present  modes  of  regarding  and 
treating  cancer,  in  that  with  all  the  immense  amount  of  research 
and  surgical  skill  that  have  been  applied  to  the  disease  its 
ravages  still  increase  in  an  appalling  manner. 

"The  proportionate  localization  ratios  shows  that  there  has 
been  special  increase  in  the  "inaccessible"  manifestations  of  the 
disease;  and  this  is  very  noticeable  in  such  organs  as  the  stomach 
and  liver,  which  comprise  the  great  majority  of  this  form  of 
disease."  Dr.  Williams  also  gives  many  illustrations  to  show 
the  fallacy  of  the  objections  which  have  been  raised  as  to  the 
reliability  of  the  figures  which  have  been  presented  every- 
where, in  many  countries,  regarding  the  increase  in  cancer 
mortality. 

Hoffman  has  collected  an  enormous  amount  of  statistics 
from  official  sources  in  regard  to  cancer  mortality  all  over  the 


20 


CANCER 


world,  which  show  a  remarkable  difference  in  different  locali- 
ties, both  as  to  the  actual  mortality  and  its  increase  over 
different  periods. 


Comparative  Mortality  from  Cancer  in  European  Countries 

1896-1910 
Rate  per  100,000  Population 


1896-1900 


1901-1905 


1906-1910 


Hungary 

Italy 

Ireland 

Austria 

German  Empire 

Scotland 

England  and  Wales. . 

Norway 

Holland 

France  (cities) 

Denmark  (cities). . .  . 
Switzerland 

Combined  average 


3° 
50 
58 
68 

70 

77 
80 

85 

9i 

97 

118 

127 


79.8 


39 

55 
68 

74 
77 
84 
86 

94 

97 

92 

129 

128 


43-6 
636 
78.8 

78.3 
84.2 

99-7 
94.0 
96.6 

i°3  S 

102 . 7 

137-3 
1259 


85-7 


92-3 


"The  high  cancer  death  rate  of  Switzerland  is  not  the  result 
of  an  increase  of  population  ages  over  45.  According  to  the 
most  recent  cancer  returns  this  proportion  was  22.16  per  cent 
of  the  population  in  Switzerland,  22.85  Per  cent  m  Denmark, 
21.36  per  cent  for  England  and  Wales  and  18.89  per  cent  f°r  the 
United  States." 

Cancer  is  known  to  differ  in  frequency  in  different  parts  of  the 
world,  and  the  following  figures  are  given  by  Hoffman1  in 
regard  to  Australasia,  Asia,  and  Africa. 


1  Hoffman,  loc.  cit.,  pp.  136-138. 


DISTRIBUTION  OF  CANCER 


Australasia 
Mortality  Rate  Per  100,000  Population 

Hawaii 4° 

Northern  Territory  (Australia) 44 

Western  Australia 59 

Queensland 63 

Tasmania 65 

New  South  Wales 73 

New  Zealand 75 

South  Australia 76 

Victoria 83 


Asia 

Ceylon 5.6 

Hongkong 8.1 

Penang 10.3 

India  (Calcutta) n .  7 

Singapore 12.6 

Philippine  Islands  (Manilla) .  27.3 

Shanghai  (Europeans) 55.3 

Japan 60 . 2 


Africa 

Mauritius 9 

Sierra  Leone 13 

Natal 32 

Algeria  (European) 34 

Transvaal 34 

Cape  Colony  (cities) 56 


It  will  be  noticed  by  these  figures  that  cancer  mortality  is 
greater  where  Europeans  congregate,  for,  as  will  be  seen  in  the 
next  chapter,  cancer  is  decidedly  a  disease  of  civilization, 
while  the  natives,  living  as  natives  in  these  same  countries, 
are  rarely  affected. 

Mortality  Rate  per  100,000  Population 


1913 


Twenty  American  cities 

Ten  English  cities 

Fifteen  German  cities.  . 

French  cities 

Seven  Italian  cities 


49.6 

89. 

57-3 

106. 

72. 1 

119. 

89.9 

104. 

83  -7 

96. 

The  following  table  given  by  Hoffman1  of  the  relative 
frequency  of  cancer  deaths  in  the  various  cities  of  the  world  is 
interesting. 


1  Hoffman,  loc.  cit.,  p.  225. 


CANCER 


International  Statistics  of  Cancer  Mortality  i 908-191 2 
Rate  Per  100,000  Population 


Calcutta '. 11 

Constantinople 34 

Rio  Janeiro 42 

Osaka 55 

Tokio 73 

New  York 77 

Chicago 78 

Philadelphia 85 

Buenos  Ayres 85 

Petrograd 85 

Sydney 90 

Moscow 94 


Liverpool 96 . 6 

Madrid 96.  7 

Rome 100.5 

Glascow 102 . 1 

Budapest 102 . 6 

Hamburg 105 . 4 

Paris 1 10. 8 

London 111.7 

Amsterdam 116.  7 

Vienna 128.9 

Berlin i33S 

Copenhagen 161 .3 


In  the  United  States  the  deaths  from  cancer  vary  also  greatly 
in  different  cities.  In  the  following  table  are  given  the  figures 
from  the  five  year  period  ending  with  1910. 


Mortality  Rate  per 

Savannah 47 . 1 

Memphis 48.  7 

Augusta,  Ga 49 . 1 

Seattle 50.2 

Charleston S3 . 6 

Jersey  City 60 . 5 

Louisville 61 . 1 

Cleveland 62 .9 

Detroit 64.5 

Minneapolis 65 . 3 

Pittsburg 66 . 4 

Nashville 68.0 

Milwaukee 68.4 

Brooklyn 68.9 

Indianapolis 70 . 4 

St.  Paul 71. 1 

Kansas  City 71 . 1 

Richmond 73 . 9 

Greater  New  York 74. 1 

Chicago 76 .  S 

Newark 76.9 


100,000  Population 

Denver 77 

St.  Louis 78 

Bor.  Manhattan  and  Bronx.  .  78 

Columbus 79 

Hoboken 80 

Philadelphia 81 


New  Orleans 82 

Buffalo 84 

Omaha 85 

Baltimore 85 

District  of  Columbia 86 

Springfield  (Mass. ) 86 

Rochester,  N.  Y 88 

Dayton 88 

New  Haven 89 

Hartford 91 

Cincinnati 93 

Los  Angeles 94 

Providence 96 

Boston 99 

San  Francisco 102 


Cancer  mortality  also  differs  materially  in  the  various  regis- 
tration states  of  the  Union,  in  regard  to  cities  and  rural  districts, 
as  shown  by  the  United  States  Mortality  Statistics  for  191 7 
(the  last  table  published). 


DISTRIBUTION  OF  CANCER 

Cancer  Mortality  per  100,000  Population  in  1917 


2.3 


States 


Cities 


Rural 
districts 


States 


Cities 


Rural 
districts 


California 

Maine 

Maryland 

Massachusetts. . . 
New  Hampshire. 
Rhode  Island — 

Montana 

Missouri 

Vermont 

Minnesota 

Connecticut 

Ohio 

Wisconsin 

Michigan 

Pennsylvania 


120 
119 
107 
106 

i°5 

101 

100 

99 

99 

98 

97 
97 
94 
92 

9i 


83.1 

101.8 

73-8 

116. s 

105. 1 

67.8 

45-i 

58.4 

109.0 

76.1 

92.0 

86.5 

77.6 

86.2 

67-3 


New  York 

Indiana 

Kentucky 

Kansas 

New  Jersey 

Colorado 

Tennessee 

Utah 

Washington 

Virginia 

North  Carolina . . 
South  Carolina.  . 

Average 


91. 


82. 
81. 
76. 
70. 
70. 
70. 
70. 
69. 


92.0 


2 

101. 

9 

89 

5 

45- 

9 

62 

3 

86 

5 

5i 

8 

40 

8 

44 

7 

46 

6 

48 

2 

40 

5 

33 

71.8 


Space  does  not  permit  of  a  very  full  consideration  of  the 
wonderful  statistics  contained  in  this  great  volume  of  Hoff- 
man's, which  is  worthy  of  much  study,  but  some  points  may 
be  mentioned. 

It  is  not  a  little  interesting  to  note  the  discrepancy  which  ex- 
ists between  the  mortality  from  cancer  in  the  cities,  (those  of 
10,000  or  more  inhabitants)  as  against  that  in  rural  districts. 

In  a  very  few  instances  the  mortality  in  the  latter  exceeded, 
and  in  a  few  it  almost  equalled  that  in  the  former,  but  in  most 
instances  and  in  the  general  average  the  rural  districts  showed 
a  far  better  per  cent. 

It  may  be  claimed  that  the  larger  number  of  cancer  deaths 
per  100,000  in  the  cities  resulted  from  the  number  of  cases  going 
there  for  treatment,  but  if  this  were  the  case  it  would  be  ex- 
pected that  the  results  of  operations  would  reduce  the  relative 
mortality  below  that  found  in  rural  districts,  where  surgical 
opportunities  were  less  favorable;  especially  is  this  true  when 
we  consider  the  large  population  of  the  cities,  which  should 
reduce  the  proportion  of  deaths  to  the  100,000. 


24 


GANGER 


An  interesting  study  has  been  made  by  Williams1  of  the  rela- 
tive number  of  deaths  from  cancer  among  men  and  women,  and 
he  gives  the  following  table. 

Increase  of  Malignant  Disease  among  Males  and  Females  per  Million 

Living 


Cancer  death  rate 

Period 

Sex  ratio 

Male 

Female 

i 851-1860 

195 

434 

1-2. 2 

1861-1870 

244 

523 

1-2 . 1 

1871-1880 

3i5 

622 

1-1.9 

1881-1890 

430 

739 

1-1.7 

1891-1900 

597 

9°3 

i-i-5 

1900-1905 

723 

997 

I-I-3 

"It  thus  appears  that,  although  there  has  been  a  great 
increase  of  malignant  disease  in  both  sexes  during  the  last  half 
century,  and  although  at  the  present  time  more  women  are 
affceted  than  men,  yet  the  malady  has  augmented  much  more 
rapidly  among  the  latter  than  among  the  former.  Moreover, 
it  is  noticeable  that  the  average  age  of  English  women  is  higher 
than  that  of  men,  so  that  the  death  rates,  as  given  above,  are 
unduly  favorable  to  the  female  sex." 

In  the  United  States  the  ratio  between  the  sexes  seems  to  be 
about  constant,  as  is  seen  in  the  following  table. 


Relation 

df  Cancer  to 

Sex 

1911 

1912 

1913 

1914 

1915 

1916 

1917 

Females 

26,499 

17,525 

28.067 
18,464 

29,883 
20,045 

31,138 
21,282 

32,066 
22,518 

34,576 
24,024 

34, 121 

Males 

24,498 

Difference 

8,974 

9,603 

9,838 

9,856 

9,548 

10,552 

9,623 

1  Williams,  loc.  cit.,  p.  57. 


DISTRIBUTION  OF  CANCER  25 

Cancer  is  relatively  less  frequent  among  certain  classes  of 
individuals  than  among  others,  and  all  evidence  seems  to  point 
to  a  lessened  mortality  from  this  disease  in  accordance  with 
certain  conditions  of  life. 

Thus,  among  the  Jews,  while  divergent  statements  have  been 
made  in  regard  to  the  relative  per  cent  of  mortality  from  cancer 
among  Jews  and  non-Jews,  there  is  a  very  considerable  unani- 
mity of  experience  that  cancer  of  the  uterus  is  very  much  less 
common  among  the  former  than  among  the  latter;  in  the  statis- 
tics from  Budapest  for  several  years,  the  ratio  of  deaths  from 
uterine  carcinoma  to  all  carcinomas  was  about  one-third,  for 
Jews.  When  the  greater  length  of  life  is  considered,  and  the 
greater  frequency  of  marriage  and  prolific  child-bearing  are 
realized,  this  very  much  smaller  proportion  of  deaths  from  the 
disease  in  this  location  is  the  more  remarkable. 

Some  observers,  however,  have  claimed  a  larger  proportion 
of  cancer  deaths  among  the  Jews  than  among  others,  but  as 
these  statements  have  been  analyzed  by  Williams1  and  Hoff- 
man2 it  would  appear  that  the  evidence  of  greater  longevity, 
together  with  the  social  position  of  different  groups  of  Jews  in 
different  localities,  would  account  for  the  diversity  of  opinions 
expressed.  The  concensus  of  opinion  seems  to  be  that  ortho- 
dox Jews,  especially  of  the  poorer  class,  observing  their  ritual 
life  are  much  less  subject  to  cancer  than  the  rest  of  any 
population. 

The  negro  race  presents  also  a  striking  instance  of  the  dif- 
ference in  the  mortality  from  cancer  under  varying  conditions. 
Quoting  from  Williams3  "In  their  native  African  homes  the 
ancestors  of  the  negro  slaves  of  the  United  States,  like  other 
similarly  situated  savages,  are  believed  to  have  been  almost 
exempt  from  malignant  tumors.  .  .  .  Transplanted  to  the 
United  States,  and  having  lived  there  in  slavery  for  over  two 
centuries,  these  negroes  have  been  found  to  have  acquired 
greatly  increased  liability  to  cancer,  to  which,  however,  they 

1  Williams,  loc.  cit.,  p.  i6ff. 

2  Hoffman,  loc.  cit.,  p.  147S. 

3  Williams,  loc.  cit.,  p.  14. 


26  CANCER 

were  very  much  less  prone  than  their  white  masters."  This  is 
clearly  shown  by  the  191 7  United  States  Mortality  Statistics. 
The  North  American  Indians  afford,  also,  an  illustration  of 
relative  immunity  from  cancer  in  their  native  state,  with  in- 
creased mortality  under  changed  conditions  of  life.  These,  and 
other  here  mentioned  facts,  will  be  more  fully  considered  in 
subsequent  chapters  on  "Civilization  and  Cancer,"  and  "Diet 
and  Cancer." 

Cancer  is  thus  seen  to  be  a  wide  spread  and  increasingly 
fatal  disease,  in  spite  of  prodigious  efforts  to  check  its  progress 
by  extensive  and  intensive  laboratory  study,  and  increasingly 
bold  and  skillful  surgery.  Of  late  there  has  also  been  strenuous 
work  put  forth  along  the  line  of  the  education  of  the  profession 
and  laity  by  various  societies  in  regard  to  the  early  recognition 
of  the  disease  and  the  necessity  for  immediate  surgical  operation. 
As  we  have  seen  in  the  previous  chapter,  and  as  will  appear 
later,  all  this  is  based  on  the  erroneous  supposition  that  cancer 
is  a  wholly  local  affection,  and  that  the  early  and  complete 
removal  of  the  particular  local  manifestation  of  the  disease  will 
effect  its  cure. 

The  fallacy  of  this  latter  supposition  has  been  abundantly 
proven  by  every  one  who  has  seen  much  of  cancer  for  many 
years,  and  by  the  steadily  rising  mortality  which  has  been  set 
forth  in  the  preceding  pages. 

For  a  hundred  and  more  years  candid  physicians  and  surgeons 
of  great  prominence  have  briefly  voiced  the  opinion  that  cancer 
was  certainly  not  a  purely  local  disease,  but  that  back  of  it  all 
there  was  some  constitutional  disturbance,  details  of  which  will 
appear  in  a  later  chapter.  In  the  study  of  the  chemistry  and 
metabolism  of  cancer  there  will  appear  the  grounds  upon  which 
its  study  and  proper  treatment  are  to  be  based. 

It  is  strange  that  the  medical  profession  should  be  so  slow  in 
accepting,  or  unwilling  to  accept  and  act  upon  the  suggestions 
along  this  line  which  have  been  thrown  out  from  time  to  time  for 
many  years  by  many  men  who  were  well  acquainted  with 


DISTRIBUTION  OF  CANCER  27 

cancer,  and  who  felt  and  expressed  their  inability  to  cope  with 
this  distressing  and  fatal  disease.  But  light  begins  to  shine, 
and  from  all  over  the  country  in  medical  societies,  book  reviews 
and  by  personal  letters,  come  the  encouraging  statements  of 
those  who  accept  the  line  of  thought  and  action  in  regard  to 
cancer  set  forth  in  these  pages. 

The  writer  is  well  aware  that  there  have  been  many  clever 
attempts  to  discredit  the  value  of  the  statistics  which  have  been 
thus  far  available  for  the  study  of  the  progress  of  cancer  through- 
out the  world.  These  relate  principally  to  the  greater  care 
exercised  by  governments  and  individual  physicians  in  regard 
to  accuracy  of  records,  etc.  But  until  better  statistics  are  pro- 
cured it  is  but  reasonable  to  work  with  those  we  have,  and  any 
criticisms  can  hardly  affect  the  fact  that  under  the  past  treat- 
ment of  cancer  the  death  rate  has  most  certainly  increased  with 
a  steady  and  really  alarming  rapidity,  especially  when  compared 
with  the  steady  decrease  in  the  mortality  from  tuberculosis. 
Whatever  the  surgeon  may  have  accomplished  in  regard  to 
"cancer  in  the  individual,"  no  progress  has  been  made,  but 
rather  the  reverse  has  occured,  in  regard  to  "  cancer  of  the  race," 
either  by  surgical  activity  or  by  the  immense  amount  of  labor 
and  money  which  has  been  bestowed  upon  laboratory  work. 


CHAPTER  III 

RELATIONS  OF  CIVILIZATION,  SO-CALLED,  TO 
CANCER 

Civilization  has  been  defined  as  a  "  reclamation  of  mankind 
from  the  savage  state,  and  instruction  in  the  arts  and  refine- 
ments of  cultivated  life,"  also  "a  condition  of  organization, 
enlightenment,  and  progress."  The  term,  being  derived  from 
the  Latin  civis,  a  citizen,  originally  implied  the  urbanization  of 
rural  or  nomadic  peoples.  But  modern  so-called  civilization  is 
quite  a  different  affair,  and  involves  modes  of  life  which  are  far 
away  from  the  simplicity  of  living  of  earlier  times  which 
conduces  to  perfect  health. 

In  the  sense  of  culture  and  refinement,  civilization  per  se  can 
hardly  be  associated  with  disease,  for  in  many  urban  communi- 
ties the  standards  of  life  have  been  simple,  and  gluttony, 
debauchery,  and  intemperance  have  been  regarded  as  vices  of  a 
lower  class  of  people,  and  have  often  been  discountenanced. 
In  regard  to  urbanization  of  nomadic  races,  this  has  been  going 
on  for  thousands  of  years,  but  there  has  never  been  a  "cancer 
problem"  until  recently,  within  a  generation.  Even  today,  in 
the  Italian  peninsula,  where  civilization  has  flourished  for 
some  4000  years,  or  since  the  days  of  the  Etruscans,  cancer  has 
hardly  become  a  menace  to  the  entire  people,  and  its  incidence 
is  still  relatively  low  and  without  great  tendency  to  increase. 
On  the  other  hand,  there  are  some  reasons  for  believing  that 
cancer  may  have  occurred  more  or  less  frequently  in  past 
centuries.  Civilization  was  not  very  far  advanced  in  England 
in  the  days  of  John  Arderne,  who  flourished  about  1300,  but 
not  only  does  his  description  of  rectal  cancer  show  a  wide 
experience,  but  he  states  clearly  that  he  had  seen  many  deaths 
from  this  cause,  and  not  a  single  recovery. 

28 


RELATIONS  OF  CIVILIZATION  TO  CANCER  29 

While  modern  civilization,  so  called  has  its  advantages,  it 
has  also  its  disadvantages.  All  recognize  that  the  mortality 
of  tuberculosis  had  been  steadily  increasing  of  late  years,  from 
the  evil  effects  of  over  crowding,  bad  sanitation,  and  erroneous 
life,  until  wiser  methods  of  treatment  have  more  recently 
succeeded  in  arresting  its  rising  progress,  and  greater  care  has 
lessened  its  death  rate  immensely,  almost  30  per  cent  since 
1900. 

Cancer  incidence  has  also  been  steadily  increasing  of  late 
years  all  over  the  world,  under  advancing  civilization,  and  the 
death  rate  has  not  diminished,  but  has  steadily  and  alarmingly 
increased  in  the  same  proportion  as  that  of  tuberculosis  has 
declined.  The  deaths  from  cancer  have  increased  so  surely  and 
persistently  that  unless  something  occurs  to  arrest  the  continued 
progress  of  the  disease,  cancer  will  soon  outstrip  tuberculosis 
in  its  morbidity  and  mortality.  For  the  death  rate  of  the  two 
have  approached  each  other  almost  60  per  cent  since  1900; 
while  tuberculosis  mortality  in  the  United  States  has  steadily 
dropped  from  201.9  per  100,000  population  to  141. 6,  or  29.8  per 
cent,  that  of  cancer  has  risen  from  63  per  100,000  in  1900  to 
81.8  in  1 91 6,  or  29.84  per  cent.  Since  that  date  it  has  fallen  a 
trifle,  possibly  owing  to  a  better  understanding  of  the  nature 
and  proper  treatment  of  the  disease.  But  in  New  York  City 
the  registered  deaths  from  cancer  actually  outstripped  those 
from  tuberculosis  in  the  period  from  July  1st  to  December 
31st,  1920;  the  deaths  from  the  latter  were  only  2,669  against 
2,691  from  cancer,  which  were  22  in  excess. 

The  rational  deduction  from  this  steady  increase  would  seem 
to  be  that  we  should  inquire  as  to  whether  there  has  not  been 
something  radically  wrong  in  our  conception  of  the  nature  of 
cancer  and  its  treatment  up  to  the  present  time.  Moreover, 
not  only  is  cancer  of  high  and  increasing  incidence  and  mortality 
in  most  civilized  countries,  but  it  also  shows  a  marked  tendency 
to  attack  primitive  and  previously  immune  races,  within  a  com- 
paratively short  time  after  they  have  lived  among  the  civilized 
whites  and  adopted  their  customs. 


30  CANCER 

But  this  seems  to  be  only  one  aspect  of  a  much  larger  problem. 
What  is  true  of  cancer  is  true  also  of  a  dozen  other  conditions 
which  are  known  collectively  as  "white  men's  diseases."  As 
such  may  be  mentioned  appendicitis,  arteriosclerosis,  cardio- 
vascular diseases  (which  now  lead  the  list  of  causes  of  death), 
renal  disease,  diabetes,  so-called  uric  acid  disease  or  atypical 
gout,  metasyphilis,  insanity,  neurasthenia,  dental  caries,  pyor- 
rhoea, etc.  Other  conditions  which  may  be  mentioned  in  the 
same  connection  are  low  birth  rate  and  race  suicide,  sexual 
anaesthesia,  increased  tendency  to  divorce  and  abandonment  of 
wives,  the  assumption  of  man's  activities  by  women,  and  much 
else  which  points  to  a  profound  upheaval  in  the  white  race.  It 
has  been  shown  that  the  Nordic  races,  which  have  for  many 
centuries  dominated  the  world,  are  in  process  of  extinction. 
They  have  been  the  world's  great  conquerors,  colonists,  and 
civilizers,  but  as  Woodruff  has  shown,  cannot  persist  racially  in 
tropical  and  sub-tropical  countries. 

From  what  we  know  of  historical  pathology  man  was  origin- 
ally immune  to  disease,  and  only  when  a  race  had  arrived  at  a 
period  of  decadence  did  it  become  subject  to  the  latter.  It  is 
conceivable  that  with  species  as  with  individuals,  longevity 
varies.  Thus,  we  can  conceive  that  what  is  called  civilization 
"ages"  a  race,  just  as  a  certain  kind  of  living  "ages"  an  individ- 
ual. The  latter  is  an  optimistic  view,  because  it  suggests  that 
regeneration  is  possible.  For  centuries  it  has  been  preached 
and  taught  that  a  return  to  primitive  customs,  so  far  as  these 
are  rational,  living  in  the  open  and  in  touch  with  Nature,  a 
simple  diet,  a  life  of  moderate  activity,  etc.,  act  as  a  preventive 
of  disease,  and  a  cure  for  disease  not  too  far  advanced.  This 
has  been  abundantly  proven  in  regard  to  tuberculosis,  in  spite 
of  the  continued  presence  of  the  bacilli. 

We  must  now  analyze  what  is  known  as  civilization,  and  iso- 
late the  factors  in  it  which  may  have  special  reference  to  the 
incidence  of  cancer,  for  the  human  being  influenced  by  so-called 
modern  civilization  differs  materially  from  the  primitive  man 
in  many  respects.     The  chief  elements  relating  to  life  are  food, 


RELATIONS  OF  CIVILIZATION  TO  CANCER  31 

sleep,  neurotic  influences,  housing,  clothing,  occupation,  habits 
of  life,  reproduction,  etc. 

Food. — This  will  be  more  fully  considered  in  a  later  chapter, 
but  some  general  points  may  be  considered.  The  more  primi- 
tive types  of  men,  and  even  some  classes  of  white  men  today, 
are  seldom  exposed  to  a  constant  surfeit  of  food.  But  the  pros- 
perous city  man  has  manifold  temptations  to  eat  and  drink 
wrongly  and  immoderately,  and  all  recognize  that  over-eating 
is  a  most  common  error.  The  appetite  is  often  increased  by 
stimulants  before  or  during  meals,  and  the  three  or  less  simple 
meals  daily,  of  the  more  primitive  or  sensible  person,  are  often 
increased  to  four  or  five.  The  Englishman  is  famed  for  his 
capacity  to  eat  as  compared  with  other  civilized  men,  but  he 
offsets  this  in  part  by  his  habits  of  exercise  and  sport.  When 
this  type  of  man  becomes  too  old  for  an  active  life,  but  continues 
to  eat,  he  suffers  from  certain  well-defined  symptoms,  which 
yield  when  he  readjusts  himself.  Later  we  shall  see  that,  as  far 
as  relates  to  cancer,  this  gluttony  involves  largely  the  consump- 
tion of  much  meat,  or  some  form  of  protein,  for  without  plenty 
of  these  substances  over-eating  is  hardly  conceivable. 

Sleep. — Those  who  see  much  of  chronic  disease,  and  study  the 
tendency  of  the  times,  recognize  that  in  so-called  highly  civilized 
communities  the  customs  in  regard  to  sleep  are  far  different  from 
those  of  some  years  ago,  and  entirely  different  from  those  of  the 
primitive  man.  Late  and  irregular  bed  hours  are  the  rule,  rather 
than  the  exception,  and  the  rest  and  refreshment  from  "Nature's 
sweet  restorer  "are  often  far  from  what  could  be  desired,  or  from 
what  was  secured  by  primitive  man.  As  contributory  to  be 
deranged  blood  cuirent  which  causes  cancer,  this  may  be  of 
significance. 

Neurotic  Influences. — Closely  connected  with  the  last  men- 
tioned element  are  the  nervous  conditions  appearing  with 
modern  civilization,  as  compared  with  those  of  the  primitive 
man.  The  uncivilized  man  is  dominated  heavily  by  custom  and 
traditional  beliefs,  and  in  adhering  to  his  tribal  customs  he 
escapes  cancer  to  a  very  large  extent.     He  must  be  quite  free 


32  CANCER 

from  ambition,  as  we  understand  the  term,  for  with  him  this  is 
limited  to  proficiency  in  war  and  hunting,  as  shown  by  his  col- 
lection of  trophies  and  spoils  of  war.  His  responsibility  is 
similarly  limited  to  playing  his  proper  role  in  tribal  life.  He  has 
few  worries,  limited  perhaps  to  fear  of  famine,  earthquakes,  etc. 
He  is  almost  always  a  fatalist,  and  this  prevents  him  from  worry. 
He  is  also  free  from  sympathy,  and  is  usually  indifferent  to  the 
woes  of  others.  Of  anything  like  home  life  he  has  no  concep- 
tion, his  hut  being  chiefly  a  place  of  refuge  in  inclement  weather 
and  a  protection  from  other  accidents.  That  it  is  a  place  to 
enjoy  life  would  never  occur  to  him.  The  uncivilized  man 
works  when  he  must  work,  and  whatever  there  is  of  routine 
drudgery  is  done  by  women.  If  we  contrast  this  life  with  that 
of  the  so-called  civilized  people,  with  their  constant  anxieties, 
rush  and  whirl  of  life,  seeking  wealth  and  pleasure,  the  differ- 
ences appear  to  be  extreme  and  conducive  to  disease. 

Clothing. — In  regard  to  this  there  is  not  much  to  say,  except 
that  the  corset  has  often  been  accused  of  being  a  factor  in  the 
causation  of  cancer  of  the  breast.  But  we  know  that  the  vagar- 
ies of  clothing  have  much  to  do  with  diseases  of  other  kinds  in 
civilized  life,  and  it  is  possible  that  some  influence  therefrom 
may  ultimately  be  traced  in  regard  to  cancer. 

Occupation. — The  contrast  between  the  occupation  of  those 
in  highly  civilized  life  and  those  living  primitive  lives  is  very 
striking,  and  we  know  that  there  are  many  occupational  dis- 
eases, and  that  some  of  them  undoubtedly  have  some  bearing 
on  the  question  under  discussion.  Chimney-sweeps'  cancer 
was  once  a  very  serious  menace  in  England  some  years  ago, 
now  averted  by  mechanical  cleaning  of  chimneys.  Workers  in 
tar,  petroleum,  and  certain  analin  chemicals  are  said  to  be  sub- 
ject to  epithelial  cancer,  and  the  disastrous  results  following 
careless  exposure  to  x-rays,  both  in  those  who  manufacture  them 
and  those  who  employ  them  therapeutically,  are  well  known 
to  all.  Sailors  and  those  much  exposed  to  the  elements  are 
subject  to  epithelioma  of  the  face  and  hands.  But,  as  stated 
elsewhere,  these  local  degenerations  of  epithelial  elements  are 


RELATIONS  OF  CIVILIZATION  TO  CANCER  33 

not  included  in  our  study  of  cancer  as  a  disease,  as  they  are 
amenable  to  local  measures  of  treatment,  which  experience 
shows  is  not  the  case  in  true  cancer  of  internal  organs,  in  which 
there  is  abundant  evidence  of  deep  constitutional  causes,  often 
of  long  standing.  Undoubtedly  some  occupations  which  lead 
to  erroneous  modes  of  living,  such  as  indulgence  in  alcohol  or 
faulty  hygienic  conditions,  etc.  may  be  shown  to  have  an  etio- 
logic  relation  to  cancer. 

Habits  of  Life. — These,  such  as  excessive  or  faulty  eating  and 
drinking,  indolence,  and  irregularities  of  many  kinds,  certainly 
have  a  very  great  bearing  on  the  production  of  cancer,  as  will 
appear  elsewhere. 

Reproduction. — With  primitive  man,  as  with  animals,  this  is 
a  normal  process,  an  integral  part  of  life,  most  cherished,  as  it 
should  be,  throughout  the  world.  But  the  differences  between 
so-called  civilized  and  primitive  types  of  human  beings  are  very 
marked  here.  The  reproductive  life  of  the  latter  is  simple, 
the  women  usually  bearing  a  child  every  second  or  third  year, 
during  the  reproductive  cycle.  In  this  way  the  reproductive 
organs  are  constantly  being  normally  occupied.  The  mothers 
suckle  their  children  normally.  In  a  sophisticated  people,  who 
are  not  necessarily  worthy  to  be  called  civilized,  birth  control, 
abortion,  contraception,  etc.,  are  all  practiced,  while  venereal 
diseases  flourish. 

It  is  not  necessary  to  go  to  primitive  people  to  visualize  the 
remarkable  change  which  has  come  over  some  of  the  white 
women  within  comparatively  recent  times.  Very  large  families 
have  been  succeeded  by  moderate,  and  these  again  by  very 
small  families,  or  none  at  all.  Here  civilization,  in  the  proper 
significance  of  the  term  has  been  at  fault,  as  shown  by  the  atti- 
tude of  the  cultivated  woman  toward  reproduction.  Appar- 
ently she  is  satisfied  to  produce  only  the  number  necessary  to 
make  up  for  the  losses  by  death.  In  ability  to  withstand  the 
shock  of  labor,  lack  of  expulsive  force,  necessitating  artificial 
aids  to  labor,  inability  or  unwillingness  to  nurse  her  child,  the 

great  increase  in  cases  of  sexual  indifference,  the  frequency  of 
3 


34  CANCER 

vaginismus,  late  marriage  and  frequent  divorce  and  desertion, 
are  all  something  recent.  The  net  result  is  that  the  uterus  and 
breasts  of  the  modern  civilized  woman  have  but  little  to  do,  and 
are  active  in  an  extremely  small  portion  of  the  reproductive 
cycle.  This  disuse  should  result  in  some  form  of  disease  or 
degeneration,  and  cancerous  disease  of  these  organs  has  shown  a 
steady  and  remarkable  increase  during  later  years.  In  Sweden 
and  some  other  countries,  where  large  families  are  the  rule, 
cancer  of  these  organs  is  rare  as  compared  with  that  of  the  stom- 
ach and  other  organs. 

We  will  now  consider  some  of  the  evidence  from  statistics  that 
the  morbidity  and  mortality  of  cancer  have  increased  to  such  a 
degree  in  countries  and  localities  where  the  influence  of  the 
white  man  and  his  customs  of  life  have  entered  largely,  that 
there  can  be  hardly  any  doubt  but  that  what  is  called  modern 
civilization  has  had  very  much  to  do  with  this  increase.  It  is 
therefore,  upon  the  recognition  and  rectification  of  these  factors 
in  its  production  that  the  true  prophylaxis  and  cure  of  cancer 
rest,  even  as  has  been  the  case  in  the  treatment  of  tuberculosis. 

Abundant  testimony  has  come  from  all  over  the  world  that 
cancer  is  very  rare  among  aborigines,  living  simple,  mainly 
vegetarian,  lives.  Supporting  this  is  the  vast  amount  of 
evidence  collected  in  the  admirable  works  of  Williams,  Hoffman, 
and  Wolff,  already  referred  to  and  from  which  we  will  quote 
largely:  Hoffman  is  particularly  impressive  in  470  pages  of 
tabular  statistics,  taken  largely  from  official  records  throughout 
the  world. 

In  New  Zealand,  according  to  Hislop  and  Fenwick,  where 
the  general  death  rate  is  the  lowest  in  the  world,  cancer  is  on  the 
increase  as  civilization  advances.  In  the  great  majority  of 
cases  the  alimentary  canal  is  the  seat  of  invasion,  even  in 
women:  all  the  patients  were  hearty  eaters,  taking  also  very 
much  strong  tea  many  times  daily. 

The  Polynesians  and  the  Melanesians  seem  to  be  peculiarly 
exempt  from  cancer.  Sir  William  McGregor,  although  he 
had  operated  several  times  on  whites  in  the  Fiji  Islands,  never 


RELATIONS  OF  CIVILIZATION  TO  CANCER 


35 


remembers  operating  for  cancer  on  a  Polynesian  or  Melanesian, 
who  are  practically  vegetarians.  He  never  saw  a  case  of  cancer 
in  British  Guiana  in  g}i  years,  and  then  saw  an  encephaloid 
cancer  of  the  tibia  in  a  Papuan,  who  for  7  or  8  years  had  lived 
practically  a  European  life,  eating  canned  Australian  meat 
daily. 

In  Australia  cancer  is  reported  to  be  very  infrequent  among 
the  natives  and  Wolff  gives  a  very  striking  table  in  regard  to  the 
progress  of  cancer  among  the  native  born  and  foreigners,  as 
follows : 


Oe  100,000  Living  There  Died  of  Cancer  in  Australia 


Number  of 

Native 

Other 

Year 

inhabitants 

born 

English 

Nationalities 

1851 

403,889 

28.0 

14.0 

1861 

1,153,973 

5-6 

30-5 

19.0 

1871 

1,168,377 

9-7 

56.7 

25.0 

1881 

2,252,167 

16.8 

72.9 

32.6 

1891 

3,183,237 

19.8 

119. 8 

45-9 

1901 

3,77i,7iS 

22.6 

203.1 

57-3 

He  remarks:  ''We  see  from  this  comparison  in  what  a 
great  degree  the  death  rate  from  cancer  has  increased  in  foreign- 
ers as  compared  to  the  native  born,  in  whom  disease  has 
remained  about  stationary,  when  the  increase  in  population  is 
considered."  Another  writer  remarks  that  when  native  Aus- 
tralians mingle  with  foreigners  as  servants  or  employees,  and 
adopt  their  diet  and  customs,  cancer  occurs  more  frequently  in 
them.  Much  the  same  has  been  reported  in  regard  to  other 
peoples  and  nationalities. 

In  regard  to  Africa,  Williams  quotes  Dr.  Madden  of  Cairo, 
who  says:  "The  concensus  of  opinion  among  medical  men  in 
Egypt  is,  that  cancer  is  never  found,  either  in  male  or  female, 
among  the  black  races  of  that  country.  Of  19,529  deaths 
among  natives  of  Cairo  in  1891,  only  19  were  due  to  cancer, 
(females  10,  males  9)  or  1  in  1,  028."     In  England  during  the 


36  CANCER 

same  year  the  proportion  was  i  :  29  deaths  from  all  causes.  In 
the  Islands  of  Lagos,  on  the  West  Coast  of  Africa,  Dr.  Johnson, 
in  14  years'  practice  there  saw  five  cases  of  cancer  in  natives, 
all  of  whom  lived  as  Europeans.  In  southern  Africa,  "among 
Boers  and  Europeans,  who  are  large  flesh  eaters,  malignant 
tumors  are  common;  but  among  the  natives,  who  are  mainly 
vegetarians,  these  tumors  are  so  rare  as  to  be  almost  unknown." 

Renner  reports  interestingly  in  regard  to  cancer  among  the 
descendants  of  liberated  Africans  or  Creoles,  in  Sierra  Leone, 
Africa.  During  30  years,  from  1870  to  1900,  there  were  but 
20  cases  of  malignant  disease  recorded  among  22,453  admitted 
to  the  Colonial  Hospital:  in  the  next  10  years  there  were  26 
among  a  total  of  10,163  general  cases,  a  low  but  steady  gain  in 
cancer  incidence,  with  the  advancing  influence  of  the  white 
man.  Every  case  of  cancer  recorded  was  in  a  Creole,  living 
like  a  European,  and  not  a  single  case  among  the  aborigines. 

In  India  all  writers  agree  that  cancer  is  rare  among  the 
natives  living  simple  lives,  although  some  have  claimed  that  the 
disease  is  more  common  than  previously  supposed;  but  its 
incidence  there  still  bears  no  relation  to  that  in  many  other 
countries,  and  an  analysis  of  some  recent  reports  explains  in  an 
interesting  and  curious  manner  the  reasons  for  the  diversity 
of  opinion  as  to  the  actual  frequency  of  the  disease. 

Thus,  Benratt  collected  a  total  of  only  1,700  cases  of  cancer 
from  5  years'  statistics  of  15  Mission  Hospitals  and  34  Govern- 
ment Hospitals,  representing  of  course  many  million  inhabitants, 
whereas  in  New  York  City  alone,  according  to  the  weekly 
Bulletins  of  the  Board  of  Health,  there  were  2,670  deaths  from 
cancer  in  the  first  six  months  of  1920:  a  striking  illustration  of 
the  relative  rarity  of  cancer  in  India.  Moreover,  of  these  1,700 
cases  in  India  over  1,200  were  about  the  mouth,  a  very  large 
share  or  almost  all  of  them  arising  from  the  very  common  habit, 
in  men  and  women,  of  chewing  betel,  which  contains  much 
calcium,  which  latter  is  one  of  the  salts  incriminated  in  the 
causation  of  cancer. 

Sandwith  also  attempts  to  show  that  cancer  is  prevalent  in 


RELATIONS  OF  CIVILIZATION  TO  CANCER  37 

India,  but  refers  to  only  2,000  cases  reported  in  the  hospitals 
there  in  3  years,  also  among  many  millions  of  people,  and  he 
refers  to  the  betel  chewing  cancer  and  the  "kangri  burn"  on 
the  abdomen  of  men,  from  the  charcoal  furnace  worn  for 
warmth;  many  have  doubted  if  the  latter  were  true  carcinoma, 
but  only  an  obstinate  local  dermatitis;  such  peculiar  local  dis- 
orders certainly  vitiate  any  deduction  which  could  be  drawn  from 
such  statistics  as  to  the  occurrence  of  true,  deep  cancer  in  India. 
Against  all  claims  as  to  the  frequency  of  cancer  in  India  may 
be  mentioned  the  fact,  stated  in  the  table  in  the  previous 
chapter,  that  the  death  rate  from  cancer  in  Calcutta  was  only 
1 1.8  per  100,000;  this  is  shown  in  the  Imperial  Cancer  Research 
scheme,  where  it  is  stated  that  the  principal  form  is  that  of  the 
buccal  cavity,  attributed  to  the  betel  chewing  by  every  native, 
it  consisting  of  tobacco,  betel  leaves,  areca  nut,  and  a  little 
slacked  lime. 

In  China  all  observers  agree  that  cancer  is  very  uncommon 
among  the  bulk  of  the  people,  but  frequent  enough  among 
Europeans  there  resident.  Hoffman  gives  some  interesting 
tables,  one  of  which  may  be  quoted. 

Mortality  from   Cancer  per   100,000,   in  hongkong,  China,  by  Race, 

iooi-iqio 

Year                               Civil  Europeans  Chinese 

1001-1905                                     49.0  5.4 

1906-1910                                    52.7  5.5 

In  Shanghai  the  cancer  mortality  among  Foreigners  had  risen 
in  1914  to  97.9  per  100.000  residents. 

Even  in  Manilla,  Philippine  Islands,  the  mortality  per  100,- 
000  among  the  Chinese  was  only  18.8  against  50.6  for  the  white 
population,  and  27.0  for  the  Philippinos,  who  naturally  mingle 
much  with  the  whites  and  follow  in  their  ways. 

In  Japan  cancer  is  much  more  prevalent  than  in  any  other  of 
the  Far  East  countries,  and  from  1899  to  191 1,  the  mortality 
had  risen  from  44.0  to  66.9  per  100,000  population.  In  the 
cities  it  was  still  greater,  in  Tokio  72.8  and  in  Kyoto  85.1,  show- 
ing clearly  the  baneful  influence  of  so-called  modern  civilization. 


38  CANCER 

In  regard  to  the  general  occurrence  of  cancer  in  the  Far  East, 
I  may  add  a  bit  of  personal  observation.  During  a  rather 
extensive  trip,  I  was  unable  to  see  or  even  hear  of  any  cancer, 
although  I  met  a  large  number  of  very  intelligent  medical  men 
and  made  diligent  inquiry  regarding  the  same.  As  I  wished  to 
verify  my  views  in  regard  to  the  rarity  of  the  occurrence  of 
cancer  among  those  who  lived  on  a  rice  or  other  vegetarian  diet, 
I  visited  very  many  civil,  military,  and  mission  hospitals,  with 
a  total  of  many  thousand  patients,  and  ministering  to  many 
millions  of  population:  in  Japan,  Korea,  China,  the  Philippines, 
India,  Siam,  and  Egypt,  I  met  the  same  response,  that  cancer 
was  rarely  seen  among  those  vegetarian  nations. 

In  the  Near  East  we  have  relatively  little  information  as  to 
the  prevalence  of  cancer.  But  only  very  recently  a  medical 
missionary,  who  has  long  been  connected  with  the  medical 
college  and  hospital  in  Beirut,  Syria,  told  me  that  cancer  was 
practically  unknown  among  the  thousands  of  patients  who  flock 
there  from  all  over  the  Near  East;  he  adding  that  they  were  all 
largely  vegetarians.  We  are  told  that  cancer  is  rare  among 
Mohammedans,  who  live  simple  lives  and  avoid  alcohol,  and  in 
the  preceding  chapter  we  saw  that  the  cancer  death  rate  in 
Constantinople  was  34.8  per  100,000  population;  and  of  these 
the  Mohammedans  had  but  22.6,  while  the  highest  rate  was 
among  the  Greeks,  who  had  56.1  per  100.000. 

Brazil,  especially  in  the  equatorial  regions,  is  credited  with 
having  the  lowest  cancer  death  record  of  any  portion  of  the 
Western  Hemisphere,  with  a  death  rate  in  1903  of  only  4  per 
100,000:  in  Rio  Janeiro  it  was  about  26  per  100,000,  showing, 
of  course,  the  effect  of  civilization.  In  Uruguay  cancer  is  com- 
paratively common,  the  death  rate  in  1897  being  47  per  100,000 
while  in  Argentina,  where  very  much  meat  is  eaten,  the  rate  in 
1900  was  91  per  100,000 

In  Mexico  cancer  is  said  to  be  fairly  common  among  those  of 
European  descent:  in  the  city  of  Mexico  the  death  rate  in  1913 
was  48.2  per  100,000,  but  the  females  were  far  in  excess  of  the 
males,  69.4  to  23.7.     In  Nicaragua  it  was  10.6,  in  British  Hon- 


RELATIONS  OF  CIVILIZATION  TO  CANCER  39 

duras,  14.7,  in  Venezuela,  14.7,  in  Jamaica,  18.4,  and  in  the 
British  West  Indies,  20.9  per  100,000. 

In  Canada  the  mortality  from  cancer  seems  to  vary  with 
the  intensity  of  civilization,  that  for  the  rural  district  of 
British  Columbia  being  30.3,  in  the  Province  of  Ontario, 
69.4,  and  in  the  city  of  Toronto,  81.9  per  100,000,  while  among 
the  aborigines  of  Canada  it  is  reported  that  the  disease  is  very 
infrequent. 

In  Iceland,  according  to  Stephanson,  who  was  specially 
requested  by  Dr.  H.  C.  Ross  to  inquire  into  the  prevalence  of 
cancer  among  the  Eskimos,  he  reported  that  he  had  found  none 
among  them  whatever. 

An  interesting  study  of  the  effects  of  modern  civilization  upon 
the  mortality  from  cancer  may  be  made  from  an  examination  of 
its  increase  in  certain  localities,  a  few  of  which  will  suffice. 

In  France,  cancer  mortality  in  1892  was  88,  and  in  1905  it 
was  100.2  per  100,000  inhabitants,  while  in  Paris  it  had  risen 
from  97.2  in  1881  to  112.4  in  1912. 

In  Germany  deaths  from  cancer  increased  from  53.5  in  189 1 
to  90  per  100,000  living  in  1912,  and  in  Berlin  from  64.6  in  1881 
to  132.8  in  191 2,  that  is  it  has  more  than  doubled  in  proportion 
to  the  living  inhabitants. 

In  Holland  the  mortality  from  cancer  rose  from  57.6  per  100,- 
000  in  1881  to  109.5  m  I9°3-  In  Amsterdam  the  rise  was  from 
72.2  to  1 14.8  in  the  same  period. 

In  Belgium  the  rise  in  the  mortality  of  cancer  was  from  59.4 
per  100,000  in  1903  to  71.3  in  191 2.  In  Antwerp  it  was  from 
47.6  in  1896  to  90.9  in  1912,  and  in  Brussels  it  rose  from  88.2  per 
100,000  living  in  1901  to  106.2  in  191 2. 

In  Italy  the  death  rate  from  cancer  was  21  per  100,000  in  1880, 
and  1912  it  was  64.7.  In  Rome  it  had  risen  from  79.1  in  1898 
to  99.6  per  100,000  in  191 2. 

Space  does  not  permit  of  the  evidence  which  has  been  so  care- 
fully collected  by  Williams,  Hoffman,  and  Wolff  to  show  the 
inter-relation  of  tuberculosis  and  cancer  to  the  conditions  of  life 
in  various  localities,  but  a  careful  study  of  the  statistics  which 


4o  CANCER 

Williams  gives  warrants  the  rather  remarkable  statement  which 
he  makes  as  follows: 

''Such  an  examination  shows  that  the  cancer  mortality  is  the 
lowest  where  the  struggle  for  existence  is  the  hardest,  the  density 
of  the  population  greatest,  the  tubercle  mortality  highest,  the 
birth  rate  highest,  the  average  duration  of  life  shortest  the 
infantile  and  general  mortality  highest,  and  where  sanitation  is 
least  perfect,  in  short  among  the  industrial  classes  in  our  large 
towns;  whereas  among  the  wealthy  and  well-to-do  where  the 
standard  of  health  is  at  its  best,  and  life  is  easiest,  and  all  condi- 
tions are  just  the  reverse  of  the  foregoing,  there  the  cancer 
mortality  is  highest." 

These  are  strong  words,  and  may  be  contested  by  some,  but 
a  very  careful  consideration  of  the  facts  and  statistics  collected 
by  Williams  will  convince  the  impartial  student  that  they  are 
not  far  from  the  truth. 

All  are  familiar  with  the  clinical  history  of  tuberculosis. 
When  from  unsanitary  surroundings,  poor  nourishment,  and 
overwork,  together  with  deficient  oxygen,  the  patient's  health 
fails,  there  comes  a  time  when  a  focus  of  tuberculosis  is  dis- 
covered, and,  unless  checked  by  a  reversal  of  the  conditions 
inducing  the  depression  of  health,  the  disease  becomes  fatal. 

With  cancer,  however,  the  clinical  history  is  quite  the  reverse. 
The  subjects  of  beginning  cancer  are  commonly  seen  to  be  in 
apparently  excellent  health:  they  are  often  ruddy  and  blooming 
in  appearance,  and  can  hardly  be  made  to  believe  that  the  dire 
disease  has  actually  begun  in  them. 

The  two  diseases  represent  exactly  two  opposite  phases  of 
nutrition,  both  induced  by  the  fundamentally  different  condi- 
tions of  life  pertaining  to  advanced  civilization.  In  the  former 
there  is  commonly  under-nourishment  with  overwork,  while  in 
the  latter  there  is  habitually  an  over-nourishment  with  under- 
work. In  the  period  from  1881  to  1890,  Dr.  Latham,  Registrar 
General,  found  the  death  rate  from  cancer  in  England  to  be 
more  than  twice  as  great  among  well-to-do  men  having  no 
specific  occupation,  as  it  was  among  occupied  males  in  general, 


RELATIONS  OF  CIVILIZATION  TO  CANCER  41 

the  mortality  ratios  being  96  for  the  former  as  against  only  44 
for  the  latter. 

If  it  were  necessary  a  mass  of  evidence  could  be  adduced  to 
show  that  cancer  is  a  disease  of  "hypernutrition,"  as  Williams 
remarks.  This  does  not  mean  that  normal  nutrition  can  be 
overdone,  if  all  the  contributing  factors  are  correct.  But  the 
complex  of  modern  civilization,  with  all  its  temptations  and 
errors  in  regard  to  eating  and  drinking  and  living,  together 
with  its  nervous  strain  felt  everywhere,  and  the  absence  of 
sufficient  and  proper  physical  exercise,  has  produced  such  a 
disturbance  in  the  normal  metabolism  and  nutrition,  that,  under 
some  slight  provocation  a  heterologous  growth  of  certain 
tissue  cells  results,  with  malignant  tendencies,  instead  of  the 
normal,  homologous,  and  stabile  structures  which  compose 
healthy  tissues:  and  this  departure  from  normal  cell  action, 
we  call  cancer.  What  these  disturbances  are  will  appear  in 
subsequent  chapters. 

The  fact  remains  that  while  cancer  is  very  infrequent  among 
primitive  people,  and  among  animals  living  in  a  state  of  nature, 
it  has  been  shown  to  increase  very  steadily  in  morbidity  and 
mortality  with  the  intensity  of  human  civilization,  and  also 
among  animals  as  they  become  domesticated,  or  kept  under 
unusual  conditions,  as  in  Zoological  Gardens  and  laboratories. 
There  cannot,  therefore,  be  any  other  conclusion  than  that 
this  dire  disease  depends  largely  upon  the  conditions  developed 
by  or  associated  with  our  artificial  existence,  to  which  is 
given  the  name  of  "modern  civilization." 


CHAPTER  IV 
HISTO-PATHOLOGY  OF  CANCER 

The  histology  of  cancer  is  a  vast  subject,  which  of  late  years 
has  occupied  the  attention  of  a  great  number  of  earnest  and 
faithful  workers,  and  it  is  quite  impossible  even  to  consider 
much  of  it  in  a  single  chapter.  But  the  endeavor  will  be  made 
to  present  sufficient  of  the  details  to  help  to  an  understanding  of 
the  subject  before  us. 

Dr.  Ewing's  monumental  work,1  of  over  one  thousand  pages, 
well  demonstrates  the  vastness  of  the  subject  and  the  difficul- 
ties of  the  study,  and  presents  many  conflicting  views  on  many 
points,  but  with  clear  judgment  in  regard  to  them;  it  is  indeed 
a  mine  of  knowledge,  from  which  I  shall  freely  draw. 

The  term  cancer  has  sometimes  been  employed  to  designate 
any  rebellious  tumor,  orneo-plastic  growth,  of  which  Ewing  gives 
a  list  of  twenty-three.  But  in  our  present  study  we  con  ide 
only  carcinoma  and  sarcoma,  the  former  a  disease  of  erratic 
epithelial  structure,  the  latter  disorder  of  the  connective  tissue 
type.  Epithelioma,  or  as  Ewing  designates  it,  "epidermoid 
carcinoma,"  affecting  the  skin,  is  not,  in  the  main,  included  in 
our  study  of  cancer  as  a  disease,  for  reasons  to  be  stated  later, 
but  much  has  been  learned  of  the  behavior  of  diseased  epithelial 
cells  from  its  microscopial  study,  and  it  will  be  first  considered. 

Cutaneous  epithelioma  represents  a  disordered  or  vicious 
growth  of  the  epithelium  of  the  epidermis,  or  of  the  glands  and 
follicles.  Ewing  makes  two  main  histological  types,  i. 
Hornifying  cancroid,  or  acanthoma,  and  2.  Basal  cell  carci- 
noma. Krompecher  named  the  two  varieties.  1.  Epithelioma 
baso-cellare,  and  2.  Epithelioma  spinocellare,  according  to  the 
layers  of  the  skin  in  which  each  is  supposed  to  originate,  and 
this  division  and  nomenclature  is  commonly  adopted.     These 

1  Ewing,  "Neoplastic  Diseases."     Philadelphia,  1919. 

42 


HISTO-PATHOLOGY  OF  CANCER  43 

two  forms  differ  materially  in  their  clinical  and  histological 
features,  the  first  being  relatively  benign,  and  seldom  metasta- 
sizing, while  the  second  is  far  more  virulent  and  destructive; 
it  is  of  much  more  rapid  growth,  and  tends  greatly  to  metasti- 
size,  as  seen  especially  when  it  occurs  on  mucous  surfaces. 

Baso-cell,  or  Tubular  Epithelioma. — This,  the  mildest  form  of 
epithelial  degeneration,  arises  from  the  basal-cells  of  the 
Malpighian  layer  and  of  the  ducts  of  the  sweat,  hair,  and  seba- 
ceous follicles. 

Microscopically  it  is  characterized  by  the  prolongation  into 
the  lower  tissues  of  plugs  or  masses  of  epithelial  elements, 
resembling  the  basal-cells  of  the  epidermis,  small,  polyhedral  or 
spindle,  with  relatively  large  vesicular  nuclei,  minute  nucleoli, 
and  scanty  cytoplasm:  no  epithelial  pearls  are  present,  and  the 
cells  invade  the  surrounding  tissue  in  groups.  In  fact  the 
cells  show  some  approach  to  those  of  an  endothelial  type,  and 
some  observers  have  maintained  that  these  growths  are  really 
endotheliomata.  These  tumors  are  strikingly  different  from 
the  ordinary  forms  of  cancer,  and  represent  the  small,  superficial, 
slow  growths  in  the  skin,  that  appear  upon  the  face,  nose,  ears, 
and  upper  lip,  and  are  relatively  amenable  to  careful  and  proper 
local  treatment:  the  x-ray  generally  removes  them,  often  with 
inappreciable  scar,  as  also  radium,  and  thorium  paste.  But, 
on  the  other  hand,  when  wrongly  treated,  as  for  instance  with 
nitrate  of  silver  or  otherwise,  they  may  become  very  destructive, 
invading  large  areas  and  extending  deeply  (rodent  ulcer,  Jacob's 
ulcer),  but  rarely  metastasize. 

Spino-cellular,  or  Lobular  Epithelioma  (the  Acanthoma  of 
Ewing). — This  is  of  quite  a  different  character.  The  tumor 
here  is  composed  of  large  cells,  with  a  relatively  great  amount  of 
protoplasm,  and  well  formed  nuclei :  the  latter  frequently  show 
mitotic  figures.  The  cells  distinctly  preserve  the  epithelial 
type,  in  form  and  characteristics,  and  intercellular  union  in  the 
form  of  prickle  cells  is  present.  Epithelial  pearls,  due  to  the 
inherent  tendency  of  the  cells  to  the  normal  life  history  of  spine 
cells,  are  a  special  feature  of  these  tumors.     The  growth  of  the 


44  CANCER 

lesions  is  rapid,  and  metastases  are  of  frequent  occurrence,  even 
in  distant  parts,  as  the  liver  and  bone-marrow.  Ewing  says 
that  "this  tumor  arises  from  previously  normal  epithelium, 
after  a  period  of  over-nutrition  and  overgrowth,  during  which 
the  sub-epithelial  tissues  become  altered  and  less  resistant. 
Lymphocytic  infiltration,  swelling  with  mucoid  or  other  forms 
of  degeneration,  followed  by  atrophy  of  elastic  tissue  and  chronic 
oedema  or  fibrosis,  usually  but  not  always  precede  the  down- 
ward growth  of  epithelium."  These  latter  descriptions  of  acan- 
thoma apply  equally  or  even  more  truly  to  epidermoid  cancer  of 
the  tongue  and  mouth. 

Gastric  Cancer. — Here  as  elsewhere  the  epithelial  element  of 
cancer  is  stikingly  manifest,  as  the  enormous  number  of  epithe- 
lial elements  lining  the  pyloric  and  peptic  glands  afford  an  ample 
source  of  malignant  degeneration,  under  the  varying  influences 
of  substances  presented  for  digestion.  Cancer  may  develop  in 
any  portion  of  the  stomach,  but  the  region  of  the  pylorus  and 
lesser  curvature  are  the  parts  most  affected,  in  even  up  to  75 
per  cent  of  the  cases.  Ewing  distinguishes  six  types  of  the 
disease,  but  the  two  principal  forms  are  adenocarcinoma  and 
scirrhus :  the  question  of  the  relation  of  peptic  ulcers  to  carcinoma 
is  still  a  disputed  one,  various  observers  place  the  relation  from 
2  or  3  per  cent  to  over  50  per  cent  of  ulcers  of  the  stomach  which 
develop  into  carcinoma.  We  will  not  here  attempt  to  discuss 
the  immense  subject  of  gastric  cancer,  but  briefly  consider  the 
two  principal  forms  of  the  disease.  All  recognize,  however, 
that  simple  ulcers  in  other  localities,  as  in  the  mouth,  can  and  do 
take  a  malignant  character,  and  there  is  no  reason  why  those 
in  the  stomach  should  not  do  the  same,  under  the  continued 
and  often  repeated  irritation  of  food,  with  a  continuance  of  the 
constitutional  condition  which  lies  at  the  bottom  of  all  cancer. 

A  deno -carcinoma  of  the  Stomach. — The  structure  of  gastric 
adeno-carcinoma  presents  somewhat  orderly  imitations  of  the 
gastric  tubule.  The  originating  tubes  become  much  elongated, 
bifurcated  and  sacculated,  and  the  tumors  are  composed  of  such 
alveoli  compactly  grouped,  with  little  stroma.     The  cells  are 


HISTO-PATHOLOGY  OF  CANCER  45 

cylindrical  or  cubital,  the  cytoplasm  clear,  and  the  nuclei  hyper- 
chromatic.  The  lumina  of  the  alveoli  are  usually  small,  or  they 
may  be  distended  with  mucus  and  exudate,  or  secondary  alveoli 
may  form  within  the  acinus.  The  adeno-carcinomas  are 
regularly  embedded  in  the  submucosa,  which  may  be  widely 
infiltrated,  and  in  the  muscularis,  which  is  usually  per- 
forated; but  extensions  to  the  lymphnodes  may  be  long 
delayed.  All  these  growths  are  comparatively  solid  on  sec- 
tion, resembling  medullary  carcinoma,  but  some  show  ac- 
cumulation of  mucus,  and  areas  of  fatty  degeneration, 
hemorrhage,  and  necrosis. 

Scirrhus  Carcinoma. — This  is  a  slowly  progressive  type  of  the 
disease,  which  is  characterized  by  its  wider  extent,  more  cellular, 
of  fibroid  nature,  and  frequent  metastasis.  The  entire  organ 
may  be  involved,  and  greatly  reduced  in  size  by  cicatricial 
contraction.  The  pylorus  and  other  areas  of  mucosa  may  be 
eroded  over  a  wide  extent,  and  pyloric  stenosis  is  common,  but 
there  is  seldom  destructive  ulceration. 

Ewing  regards  it  as  thoroughly  attested  that  carcinoma  of  the 
stomach  arises  from  the  previous  normal  glands,  through  a  proc- 
ess beginning  as  localized  overgrowth,  and  that  this  takes 
place  primarily  in  the  epithelial  cells,  which  usually  show  pre- 
liminary disturbances  of  over-nutrition  and  excessive  function, 
as  was  mentioned  in  cutaneous  epithelioma.  There  is,  however, 
a  considerable  gap  between  the  ordinary  condition  of  inflamma- 
tory overgrowth  and  definite  adeno-carcinoma  in  the  stomach, 
and  this  gap  appears  to  be  bridged,  if  at  all,  by  a  rather  sharp 
morphological  change  which  is  established  rapidly.  The  single 
glands  and  minute  groups  of  glands  exhibit  a  pronounced  altera- 
tion, while  surrounded  by  normal  or  slightly  altered  tubules. 
The  original  cancerous  area  may  be  single  or  composed  of 
multiple  foci,  which  later  fuse  together.  From  this  area  of 
origin  the  tumor  tends  to  grow  from  its  own  elements. 

The  enormous  supply  of  lymphatics  in  the  stomach  play  a 
most  important  part  in  the  extension  of  cancer  and  in  metastasis 
elsewhere,  and  the  impossibility  of  absolutely  eradicating  all 


46  CANCER 

slightly  affected  nodes  explains  in  part  the  unsatisfactory 
ultimate  results  of  surgical  procedure. 

But  cancer  of  the  stomach  also  extends  itself,  and  involves 
adjoining  tissues  by  its  well  known  tendency  to  advance  into 
any  organ  or  part  contiguous  to  it,  for  cancer  respects  no  anat- 
omical divisions.  Cancer  may  also  spread  through  the  vascular 
system,  as  when  it  ulcerates  into  a  vein,  and  as  the  blood  vessels 
of  the  stomach  communicate  directly  with  the  portal  system, 
the  liver  is  most  commonly  affected.  When  the  disease  has 
advanced  so  as  to  involve  the  peritoneum,  free  cancer  cells  may 
be  scattered  over  the  general  peritoneal  cavity  and  even  be 
found  upon  the  anterior  surface  of  the  rectum. 

Carcinoma  of  the  Intestine. — This  differs  greatly  in  frequency 
in  different  portions  of  the  intestinal  tract,  from  being  very  rare 
in  the  duodenum,  more  common  in  the  colon,  and  most  frequent 
in  the  sigmoid  flexure  and  in  the  rectum:  it  may  occur  in 
younger  persons  than  cancer  in  other  locations.  The  histo- 
pathology  is  much  the  same  as  in  carcinoma  of  other  mucous 
surfaces,  adeno-carcinoma  predominating. 

The  disease  arises  usually  in  a  circumscribed  area  of  mucosa, 
in  which  the  glands  become  enlarged,  the  lining  cells  hypertro- 
phied  and  multiplied,  and  bifurcated.  The  neoplastic  alveoli 
soon  break  through  the  muscularis  mucosae,  and  extend  along 
the  submucosa,  often  reaching  the  surface  at  lateral  points,  and 
thus  extending  the  lesion,  or  penetrating  the  muscularis  along 
lymph  and  blood  vessels.  In  the  early  stages  of  most  cases, 
and  in  some  instances  throughout  the  disease,  there  is  a  gradual 
extension  of  the  area  of  origin  by  the  progressive  transforma- 
tion of  normal  into  neo-plastic  alveoli.  Intestinal  polypi  play 
an  important  part  in  the  histogenesis  of  cancer  in  the  large 
intestine. 

As  in  cancer  in  all  other  localities,  continued  local  irritation 
is  probably  the  effective  agent  in  the  actual  localization  of  the 
diseased  process  in  the  intestinal  tube.  Thus,  the  largest  num- 
ber of  cancers  occur  in  the  sigmoid  flexure  and  rectum,  where  the 
fecal  matter  is  more  solid,  and  may  be  retained  for  some  time, 


HISTO-PATHOLOGY  OF  CANCER  47 

while  it  is  least  frequent,  or  very  rare,  in  the  descending  colon, 
which  is  empty  much  of  the  time,  and  again  more  common  in  the 
transverse  colon.  The  pendant  cecum,  at  the  other  end  of  the 
colon,  which  first  receives  irritating  and  other  substances 
from  the  ilium,  and  where  there  is  often  an  accumulation,  and 
also  the  appendix,  are  frequent  sites  of  cancer  in  the  intestine. 

Cancer  of  the  Rectum  and  Anus. — In  19 14  this  caused  the 
death  of  2,171  persons  in  the  registration  district  of  the  United 
States,  4.1  per  cent  of  all  carcinomas,  or  3.3  persons  per  100,000 
population.  Over  80  per  cent  are  due  to  adeno-carcinoma,  and 
a  small  percentage  to  epithelioma,  beginning  at  the  anus. 
Within  the  rectum,  as  in  the  case  of  the  urinary  bladder,  polypi, 
which  are  quite  abundant,  appear  to  be  the  starting  point  of 
the  malignant  disease.  The  anatomical  form  of  the  carcinoma 
varies  extremely.  The  polyps  may  be  very  small,  very  numer- 
ous, widely  distributed,  and  the  entire  mucosa  hyperplastic, 
or  they  may  be  large  and  less  numerous.  The  carcinomatous 
process  usually  begins  in  a  single  polyp,  involving  others  later: 
as  a  rule,  one  or  more  of  the  polyps  are  malignant,  the  others 
benign.  In  structure  the  tumors  show  various  types,  malignant 
adenoma,  adeno-carcinoma,  and  alveolar  carcinoma.  Ulcer 
of  the  rectum  may  degenerate  into  a  carcinoma,  but  it  is  not 
thought  that  hemorrhoids  have  any  great  predominating  cause. 
Constipation,  with  the  urgent  efforts  of  the  rectum  to  relieve 
itself,  is  certainly  a  very  important  element  in  its  causation. 

Carcinoma  of  the  pancreas  is  not  infrequent,  as  a  primary  or 
secondary  disease,  it  representing  1.3  per  cent  of  all  deaths  from 
carcinoma  in  the  United  States  in  1914,  with  a  rate  of  one 
person  per  100,000  population. 

The  location  of  the  tumor  is  usually  in  the  head  of  the  pan- 
creas, or  extending  diffusely  over  most  of  the  organ,  and  the 
tail  is  rarely  affected.  Two  main  types  of  pancreatic  carcinoma 
are  observed:  1.  Cylindrical  cell  adeno-carcinoma,  arising 
from  the  ducts,  and  2.  Carcinoma  simplex,  arising  from  the 
parenchyma.  The  structure  of  adeno-carcinoma  is  composed 
of  papillary  outgrowths  and  alveoli,  lined  by  cylindrical  or 


48  CANCER 

cuboidal  cells.  The  local  extensions  of  the  tumor  have  been 
traced  through  ducts,  lymphatics,  and  nerve  trunks.  Carcin- 
oma of  the  parenchyma  produces  a  more  diffuse,  rapidly  grow- 
ing tumor,  which  is  firm  or  soft  according  to  the  proportion  of 
fibrous  tissue.  The  cells  are  small  or  large,  granular,  hydropic, 
or  fatty,  resembling  those  of  the  pancreatic  alveoli.  The  cell 
borders  are  often  indistinct,  and  the  vesicular  nuclei  occupy 
most  of  the  cell.  Nucleoli  are  poorly  developed,  and  the 
relatively  large  size  of  the  nuclei  is  often  a  notable  feature. 
Large  mononuclear  giant  cells  may  appear  in  numbers,  and  also 
in  metastases.  The  origin  of  this  tumor  has  been  traced, 
in  an  early  case,  to  the  pancreatic  alveoli,  and  the  transforma- 
tion of  gland  cells  into  tumor  cells  has  been  sketched  in  detail. 
Extensions  throughout  the  pancreas  occur  early  and  travel 
fast  by  ducts,  lymphatics,  blood  vessels,  nerve  trunks  and 
alveolar  spaces.  The  islands  of  Langerhans  are  usually  hyper- 
trophied,  and  may  be  much  increased  in  number,  showing 
many  transitions  from  secreting  to  island  tissue. 

Carcinoma  of  the  Liver. — Primary  cancerous  disease  of  this 
organ  is  very  rare,  but  from  its  connection  with  and  approxi- 
mation to  other  organs  the  deaths  from  cancer  of  the  liver  and 
the  gall  bladder  caused  the  death  of  9.8  persons  per  100,000 
living  in  the  United  States  in  1914,  a  little  over  one-half  of 
the  number  being  attributed  to  cancer  of  the  stomach. 

Considerable  difference  of  opinion  exists  in  regard  to  hepa- 
toma, or  tumors  in  general  which  affect  the  liver,  and  their 
connection  with  cirrhosis,  and  it  is  difficult  to  present  a  concise 
statement  in  regard  to  carcinoma  of  this  organ;  Ewing  makes 
seven  varieties  of  neo-plastic  hyperplasia. 

Primary  cancer  of  the  liver  undoubtedly  begins  as  an 
adenoma,  with  angiocholitis  proliferans  as  an  antecedent.  It 
has  also  been  shown  that  there  is  a  uniform  gradation  between 
nodular  hyperplasia,  multiple  adenoma,  and  multiple  carcinoma. 
During  the  transition  the  cells  may  retain  the  granular 
character  of  liver  cells,  while  staining  more  intensely  with 
basic  dyes,  or  they  may  lose  granules  and  pigment  and  assume 


HISTO-PATHOLOGY  OF  CANCER  49 

a  transparent,  embryonal  character.  Nuclear  hypertrophy 
and  hyper-chromatism  are  very  constant,  multi-nucleated 
giant-cells  appear,  and  mitosis  and  amitosis  are  frequent. 

Notable  changes  in  the  nuclei  are  often  seen  in  neighboring 
liver  tissue,  forming  a  feature  of  collateral  hyperplasia. 

Secondary  cancer  of  the  liver  may  affect  a  large  portion  or 
the  whole  of  the  organ.  The  liver  may  be  greatly  increased  in 
size,  extending  an  inch  or  more  below  the  costal  cartilages,  and 
its  edge  irregularly  nodular.  The  whole  surface  becomes 
studded  with  white,  carcinomatous  masses.  The  microscopical 
structure  shows  extensive  replacement  of  parenchyma  by 
adenomatous  and  carcinomatous  nodules.  The  process  begins 
with  hypertrophy  and  hyperplasia  of  cell  groups,  within  the 
acinus,  and  apparently  at  any  point  within  the  lobule.  These 
cell  groups  enlarge,  forming  nodules,  which  rapidly  encroach 
upon  the  remaining  parenchyma,  with  atrophy.  The  tumor 
cells  are  of  large  size,  forming  thickened  liver  cords,  or  the 
nuclei  multiply  actively,  and  numerous  smaller  cells  resu  t. 
Peculiar  forms  of  nuclear  division,  chiefly  of  the  amitotic  type 
are  observed :  giant  and  syncytial  masses  often  appear.  Fatty 
degeneration  may  be  prominent,  and  liquefaction  may  be  added. 
The  cells  may  be  arranged  in  small  regular  alveoli,  with  a  fine 
lumen,  or  the  lumen  may  be  wide,  and  the  lining  cells  low 
cuboidal.  Many  transitions  from  adenoma  to  adeno-carcinoma 
are  observed. 

Carcinoma  of  the  gall  bladder  and  ducts  exhibits  about  the 
best  proof  of  the  local  disease  developing  as  the  result  of  long 
continued  local  irritation,  some  having  claimed  that  in  as  high 
as  75  per  cent  of  cases  gall  stones  were  found.  But  on  the 
other  hand  in  about  4,000  operations  at  the  Mayo  clinic  on  the 
gall  bladder  and  biliary  ducts,  only  about  2.25  per  cent  were  for 
malignant  conditions.  Furthermore  the  innumerable  success- 
ful operations  for  cholelithiasis,  where  no  cancer  existed,  show 
that  even  this  prolonged  local  irritation  is  not  sufficient  to 
induce  the  disease,  unless  the  constitutional  conditions  exist 
which  predispose  to  cancer:  for  we  know  that  there  may  be 


50  CANCER 

immense  concretions  of  gall  stones,  dating  back  for  years,  even 
25,  without  cancer,  and  symptoms  of  gall  stones  are  said  to  be 
absent  in  the  majority  of  cases  of  carcinoma  of  the  gall  bladder. 
Aside  from  minor  variations  the  established  disease  presents 
two  main  structural  types:  1.  Adeno-carcinoma,  and  2.  Alveo- 
lar   carcinoma. 

Adeno-carcinoma  is  the  most  frequent  form  and  produces 
papillary  and  scirrhous  growths,  and  become  universal  in 
certain  cases,  which  run  the  course  of  bulky  and  widespread 
gelatinous  carcinoma.  They  early  tend  to  perforate  the  wall 
and  extend  to  the  peritoneum. 

In  the  scirrhous  type  extensive  new  growth  of  fibrous  tissue 
surrounds  the  isolated  adenomatous  alveoli  in  the  gall  bladder, 
but  in  the  lymph  nodes  and  liver  the  cells  grow  more  rapidly 
and  fibrosis  is  wanting:  the  extent  of  the  fibrosis  is  often 
remarkable. 

Alveolar  carcinoma  in  the  gall  bladder  presents  the  usual 
features  of  this  neo-plastic  process.  The  most  malignant 
growths  are  composed  largely  of  pseudo-alveoli  of  small  cuboidal 
or  rounded  cells.  Others  show  many  traces  of  adeno-carcino- 
matous  structure,  and  the  frequent  transition  of  one  type  into 
the  other  indicates  that  both  arise  from  the  same  glandular 
structure  in  the  mucosa. 

Squamous  cell  carcinomata,  pure  or  associated  with  cylindri- 
cal cell  carcinoma,  are  not  infrequently  observed,  in  which  the 
squamous  characters  with  pearls  and  spinecells  may  be 
found. 

Cancer  of  the  Ampulla  of  Vater. — Carcinoma  arises  in  the 
corrugated  mucosa  of  this  structure,  and  at  the  duodenal 
papilla,  but  except  in  very  early  cases  it  is  very  difficult  to 
determine  the  exact  origin  of  the  tumors.  The  tumors  are 
small,  villous  or  papillary  growths,  or  diffuse  infiltrations  of  the 
wall.  Columnar  cell  adeno-carcinoma  is  the  type  almost 
always  observed:  the  architecture  is  villous,  fungoid,  or  infil- 
trating, without  much  variation  in  structure,  with  alveoli  lined 
by  smaller  cubical  or  rounded  cells. 


HISTO-PATHOLOGY  OF  CANCER  5 1 

Carcinoma  of  the  Kidney. — The  term  hypernephroma,  or 
adrenal  rest  tumor,  has  of  late  years  been  applied  to  all  malig- 
nant tumors  of  the  kidney,  but  Ewing  rejects  that  name,  and 
very  clearly  differentiates  real  carcinomatous  tumors  of  the 
kidney,  arising  from  its  own  epithelial  elements.  He  discusses 
adrenal  disease  separately,  under  seven  sub-divisions,  as  affect- 
ing the  cortical  or  medullary  divisions  of  the  organ. 

Malignant  tumors  of  renal  epithelium  appear  in  two  main 
forms:  1.  Papillary  adeno-carcinoma,  and  2.  Alveolar  carcin- 
oma. In  general  it  may  be  stated  that  the  two  forms  of  car- 
cinoma accord  with  the  two  chief  groups  of  adenoma,  from 
which  many  of  them  arise. 

1.  Papillary  adeno-carcinoma  is  the  most  frequent  of  renal 
growths,  of  which  three  forms  are  recognized:  (a)  Papillary 
adenoma  and  carcinoma  with  clear  or  glassy  cells:  (b)  Papillary 
adeno-carcinoma,  or  carcinoma  with  granular  cells,  and:  (c) 
Malignant  tumors  arising  from  simple  cystadenoma. 

The  first  of  these  produces  large,  single,  less  often  multiple, 
yellowish,  circumscribed,  vascular  or  hemorrhagic  tumors, 
composed  of  villous  or  thin  papillary  strands  of  connective 
tissue,  lined  by  one  layer  of  cubical  or  cylindrical,  clear,  fatty 
epithelium. 

The  second  form  appears  as  multiple,  solid,  whitish  and  cellu- 
lar growths,  less  distinctly  encapsulated,  commonly  free  from 
hemorrhage  and  composed  of  numerous  branching  strands  of 
connective  tissue,  lined  by  one  or  several  layers  of  opaque, 
granular  epithelium,  free  from  fat. 

The  third  group  includes  cystadenomas  which  have  become 
malignant. 

In  advanced  and  fatal  cases  these  tumors  become  very  large, 
destroying  most  of  the  kidney,  and  undergoing  further  necrosis, 
hemorrhage  and  cystic  softening.  They  extend  by  continuity 
to  kidney,  renal  pelvis  with  hydro-nephrosis,  adrenal,  lymph- 
nodes,  and  abdominal  walls,  and  they  invade  the  renal  and 
other  veins,  often  very  early.  Metastases  are  very  frequent  in 
the  lungs,  liver,  and  bones,  chiefly  in  ribs,  spine,  skull,  scapula, 


52  CANCER 

and  long  bones,  sometimes  even  8  to  10  years  after  removal  of 
the  primary  tumor. 

2.  Alveolar  Adeno-carcinoma. — In  this  group  are  included  the 
majority  of  malignant  alveolar  tumors  of  the  renal  epithelium. 
They  are  clearly  separable  from  the  carcinoma  with  clear  cells, 
from  papillary  carcinoma,  and  from  adrenal  growths.  The 
structure  is  uniformly  alveolar  or  tubular,  adult  in  type,  and 
resembles  the  renal  parenchyma.  These  tumors  probably 
originate  from  well-differentiated  renal  blastema  or  from  adult 
cortical  tubules.  These  neoplasms  may  arise  from  any  portion 
of  the  kidney,  and  may  be  located  chiefly  in  the  cortex  or  pelvis, 
which  are  widely  distended,  or  beneath  the  capsule,  or  they 
may  be  extra-renal.  Most  of  the  tumors  reach  considerable 
and  sometimes  large  dimensions.  Fatty  changes,  hemorrhage, 
and  necrosis  are  not  prominent,  but  the  solid,  lobulated,  opaque 
texture  serves  to  distinguish  them  from  adrenal  growths  and 
papillary  carcinoma:  small  cysts  containing  gelatinous  material 
are  not  infrequent.  The  highly  malignant  tumors  infiltrate  the 
kidney  diffusely,  perforate  the  pelvis  and  capsule,  invade  both 
veins  and  lymphatics,  and  produce  metastases  in  many  organs. 

Carcinoma  of  the  Urinary  Bladder. — The  deaths  from  carci- 
noma of  the  bladder  were  1.5  persons  per  100,000  in  the  United 
States  in  1914,  half  more  than  those  from  the  pancreas.  Car- 
cinoma of  the  bladder  seems  somewhat  of  a  mystery.  Its  incep- 
tion does  not  seem  to  be  traced  to  any  one  cause  of  continued 
local  irritation,  as  in  the  gall  bladder,  intestines,  mouth,  etc., 
but  simply  to  the  liability,  from  unknown  cause,  of  the  sluggish 
tendency  of  certain  cells  to  take  on  malignant  action;  it  is  the 
best  illustration  of  chronic  inflammation  affording  the  basis 
for  malignant  transformation  of  epidermic  cells. 

Vesical  calculi  are  charged  as  the  irritative  cause,  in  propor- 
tions varying  greatly  with  different  authors,  up  to  30  per  cent 
of  the  cases;  but  in  Judd's  series  of  in  malignant  growths  they 
were  present  in  only  two  cases.  On  the  other  hand,  we  know 
of  vesical  calculi  existing  for  even  25  years  without  the  produc- 
tion of  cancer,  and  this  disease  is  relatively  seldom  found  in  the 


HISTO-PATHOLOGY  OF  CANCER  53 

multitudinous  cases  in  which  stones  are  removed  from  the  kid- 
ney, ureters,  or  bladder. 

Chronic  cystitis  is  also  charged  as  a  cause,  as  it  naturally 
exists  when  cancer  is  found  surgically.  But  the  same  argument 
pertains  as  in  regard  to  calculi,  seeing  the  large  numbers  of 
subjects  having  chronic  cystitis  for  years  without  carcinoma- 
tous developments. 

Papillomata,  however,  and  mucous  polyps,  are  very  frequent 
in  the  bladder,  and  while  many  of  them  are  benign,  which  have 
lasted  18,  30,  and  even  60  years,  it  is  claimed  that  in  25  per  cent, 
of  cases  they  become  malignant  after  a  variable  period;  while 
some  few  of  them  are  malignant  from  the  first,  and  occasionally 
the  removal  of  a  benign  papilloma  will  be  followed  by  the 
development  of  carcinoma.  Adeno-carcinoma  may  also  be 
found  in  the  bladder,  though  rarely. 

Signs  of  malignancy  in  papillomas  include  much  variation  in 
the  size  and  type  of  the  cells,  and  extensive  and  irregular  over- 
growth, but  the  most  important  indications  may  be  found  in  the 
pedicle,  which  is  seldom  accessible  in  operative  material. 
Downward  growth  of  the  convoluted  epithelium,  invading  the 
pedicle  and  subjacent  tissue,  is  the  chief  factor  in  local  recur- 
rence and  malignancy.  There  is  reason  to  believe  that  chronic 
inflammation  with  oedema  and  round  cell  infiltration  facilitate 
this  downward  growth  and  renders  it  posible,  without  any 
great  change  in  the  growth  capacities  or  morphology  of  the  cells. 
Frankly  malignant  papillomas  exhibit  throughout  the  atypical 
and  lawless  growth  of  carcinoma.  Primary  cancer  of  the  blad- 
der is  thought  to  be  relatively  rare. 

Secondary  invasion  of  the  bladder  from  the  prostate,  rectum, 
and  uterus,  etc.,  is  not  uncommon,  and  the  differential  diag- 
nosis between  this  and  primary  tumor  is  often  difficult,  and 
at  times  impossible. 

Cancer  of  the  prostate  caused  the  death  of  1.2  persons  in  100,- 
000  population  in  the  United  States  in  1914,  and  the  proportion 
of  cancerous  disease  in  operative  cases  of  prostatic  trouble  has 
been  stated  at  from  16.5  to  21  per  cent.     The  common  form 


54  CANCER 

of  malignant  disease  of  the  prostate  is  adeno-carcinoma, 
although  scirrhus  carcinoma,  and  squamous  epithelioma  or 
acanthoma  may  occur. 

The  typical  adeno-carcinoma  presents  large  spaces  filled  with 
masses  of  atypical  cells,  forming  numerous  secondary  alveoli. 
The  size  of  the  cells  varies  from  large,  clear,  prostatic  epithelium 
to  small,  granular,  acidophile  cells,  and  the  carcinomas  derived 
from  them  present  corresponding  varieties.  The  simplest  form 
of  adeno-carcinoma  is  the  structure  usually  observed  in  the 
suspicious  and  pre-cancerous  areas  of  chronic  hypertrophy,  but 
compact  groups  of  small  alveoli,  as  in  malignant  adenoma,  also 
occur  in  these  cases,  and  occasionally  multiple  layers  of  atypical 
cells  completely  fill  the  alveolus,  and  the  structure  passes 
directly  into  solid  carcinoma.  Pure  adeno-carcinoma  is  doubt- 
less not  so  active  and  aggressive  as  alvelolar  carcinoma,  and  its 
presence  probably  signifies  that  a  preliminary  period  of  rela- 
tively slow  growth  has  preceded  the  more  malignant  carcinoma 
with  which  it  is  usually  associated. 

Carcinoma  of  the  prostate  presents  many  variations  in  struc- 
ture. A  pseudo-alveolar  type  is  assumed  where  very  numerous, 
small  groups  of  cells,  inclosing  a  definite  lumen,  are  closely 
packed  together,  and  infiltrate  the  stroma,  gland,  capsule,  and 
nodes.     This  is  really  a  more  malignant  form  adeno-carcinoma. 

The  prostate  is  very  richly  supplied  with  lymphatics,  which 
play  an  important  part  in  connection  with  the  disease.  They 
anastomose  with  the  rectal  vessels,  also  with  the  bladder,  and 
there  are  very  rich  connections  with  the  seminal  vesicles,  and 
with  the  general  lymphatic  system,  and  involvement  of  the 
thoracic  and  cervical  nodes  are  not  infrequently  observed. 
Various  organs  have  been  involved,  liver,  kidneys,  adrenals, 
pancreas,  peritoneum,  lungs,  pleura,  dura,  brain,  heart,  thy- 
roid, and  spleen.  The  bones  are  also  attacked,  and  it  has 
been  estimated  that  about  70  per  cent  of  prostatic  car- 
cinoma cause  skeletal  metastases;  the  spinal  column,  pelvis, 
long  bones,  skull,  ribs,  sternum,  scapule  and  clavicle  have  been 
thus  affected. 


HISTO-PATHOLOGY  OF  CANCER  55 

Carcinoma  of  the  Uterus. — In  the  United  States,  registration 
area,  in  1914,  there  were  7,470  deaths  from  cancer  of  the  uterus: 
this  was  14.3  per  cent  of  all  deaths  from  carcinoma,  and  11.3 
persons  per  100,000  population.  Other  statistics  have  placed 
the  frequency  much  higher,  up  to  15.59  per  cent  of  the  total 
cancer  deaths  in  both  sexes,  and  as  high  as  30  to  38  per  cent  of 
all  those  occurring  in  women. 

Two  main  histological  and  clinical  varieties  of  uterine  car- 
cinoma are  recognized:  1.  Squamous  cell  carcinoma  of  the 
cervix,  and  2.  Glandular  carcinoma  of  the  body.  The  vaginal 
portion  of  the  cervix  is  almost  exclusively  the  seat  of  epider- 
moid carcinoma:  in  the  cervical  canal  the  two  types  meet  and 
intermingle,  while  glandular  carcinoma,  or  malignant  adenoma, 
predominates  in  the  corpus. 

Cervical  Carcinoma. — In  cervical  carcinoma,  which  forms  at 
least  90  per  cent  of  uterine  carcinoma,  two  histological  types  of 
structure  appear,  epidermoid  carcinoma  and  adeno-carcinoma, 
but  the  two  types  are  often  combined.  The  most  frequent 
presents  cords  of  pavement  epithelium  in  which  neither  alveoli, 
pearls,  spine  cells,  nor  hornification  are  demonstrable.  Rarely 
adult  acanthoma  is  observed,  with  abundance  of  pearls  and 
much  hornification.  These  structures  usually  affect  the  portio 
vaginalis  and  ulcerate  early. 

The  established  tumor  is  usually  composed  of  columns  of 
transitional  epithelium,  with  cells  of  large  dimensions,  polyhe- 
dral or  rounded,  without  a  trace  of  pearl  formation  or  keratosis; 
giant  cells  are  commonly  frequent.  The  stroma  is  usually 
scanty,  vascular,  and  infiltrated  by  mononuclear  or  eosinophile 
leukocytes.  Evidently  this  structure  is  produced  by  the  growth 
of^the  epithelial  layer  as  a  whole,  which,  in  order  to  accommodate 
its  enlarged  dimensions,  becomes  variously  folded,  incurved,  or 
everted,  thus  resulting  in  a  bulky  tumor  of  essentially  papillary 
type.  This  structure  produces  the  majority  of  the  papillary 
or  cauliflower,  superficial,  or  deep  tumors  of  the  cervix.  Their 
histogenesis  has  been  traced  to  the  stratified  epithelium  lining 
the  cervical  canal  and  the  ducts  of  the  glands.     This  metaplasia 


56  CANCER 

may  extend  to  the  endometrium,  where  changes  occur  in  many 
cases  of  cervical  carcinoma.  Adeno-carcinoma,  reproducing 
the  alveoli  of  the  cervical  glands,  occurs  in  a  small  proportion 
of  cervical  carcinomas. 

Carcinoma  of  the  Corpus  Uteri. — The  histogenesis  of  corpus 
carcinoma  presents  many  difficulties,  and  in  spite  of  much  labor 
the  exact  origin  of  the  different  histological  types  remains  un- 
certain.    Ewing  recognizes  four  forms  of  disease. 

i.  Malignant  adenoma,  the  most  frequent  type,  presents 
greatly  enlarged  and  elongated  alveoli,  giant  reproductions  of 
the  uterine  glands,  lined  by  several  compact  layers  of  cuboidal 
and  cylindrical  cells.  The  cell  bodies  are  usually  paler  than  the 
normal  lining  cells,  but  the  large  hyperchromatic  nuclei  give 
a  dark  staining  character  to  the  gland  linings. 

2.  Papillary  adeno-carcinoma  is  a  form  assumed  by  certain 
tumors  which  probably  arise  from  superficial  cells  or  adenoid 
forms.  They  may  closely  resemble  in  structure  and  gross 
appearance  the  coarser  papillomas  of  the  bladder,  but  are 
usually  diffuse  and  compact.  Various  stages  of  malignant 
transformation  of  benign  polyps  are  observed. 

3.  Alveolar  carcinoma  is  rare  in  the  uterus,  but  some  tumors 
early  show  solid  masses  of  cells  forming  alveoli,  and  smaller 
cell  groups  infiltrating  spaces  and  vessels. 

4.  Squamous  cells  may  form  a  prominent  element  in  adeno- 
carcinoma of  the  corpus,  and  in  rare  cases  they  predominate  over 
the  glandular  structure,  and  produce  a  true  adeno-acanthoma. 
While  in  many  cases  neither  spine  cells  nor  keratohyaline 
granules  are  demonstrable,  in  others  both  these  criteria  or  true 
squamous  epithelium  are  present,  and  pearl  formation  is  added. 

The  frequent  association  of  adeno-carcinoma  with  myoma 
suggests  that  the  originating  glands  may  be  in  some  way  con- 
nected with  a  myomatous  area,  or  other  developmental  anom- 
ally.  From  10  to  25  per  cent  of  corpus  carcinoma  are  said  to 
be   associated  with  myomas. 

Carcinoma  of  the  Breast.— In  the  United  States  registration 
area  during  1914,  there  were  5,423  deaths  from  cancer  of  the 


HISTO-PATHOLOGY  OF  CANCER  57 

breast  out  of  a  mortality  of  52,420  from  cancer  in  general, 
something  over  10  per  cent,  and  17.4  per  cent,  of  the  total 
deaths  from  cancer  in  women. 

Cancer  of  the  breast  has  very  naturally  been  the  object  of 
histological  study  more  than  that  of  any  other  organ,  and 
great  diversity  of  opinion  exists  in  regard  to  many  points 
concerning  it:  it  is  quite  impossible  in  the  present  writing  to 
compass  the  subject  at  all  fully,  but  the  attempt  will  be  made  to 
give  enough  to  render  the  subject  fairly  clear.  It  is  interesting 
to  realize  that  as  Ribbert  says:  "No  one  has  ever  seen  a 
beginning  carcinoma  of  the  breast,"  nor,  it  might  be  added, 
in  any  other  location. 

Ewing  says:  "While  there  are  several  well  defined  forms  of 
mammary  cancer,  the  specific  features  characterize  chiefly  the 
early  forms  of  the  disease.  Arising  under  markedly  different 
conditions  of  a  wide  variety,  the  anatomical  distinctions  are 
often  obliterated  when  the  disease  is  fully  established  and  the 
local  lymphatics  are  invaded.  On  chiefly  anatomical  features 
the  disease  may  be  considered  under  the  following  forms," 
according  to  Ewing:  "1.  Adeno-carcinoma,  arising  chiefly  in 
cysts  of  ducts  or  sweat  glands:  2.  Duct-carcinoma,  arising 
from  the  lining  cells  of  ducts:  and  3.  Acinar-carcinoma,  arising 
from  the  epithelium  of  the  acini;  of  these  main  groups  there  are 
several  sub-divisions,  such  as  gelatinous  or  mucous  carcinoma, 
fibro-carcinoma,  and  carcino-sarcoma,  while  striking  clinical 
features  stamp  certain  cases  of  the  disease  as  highly  specific." 
We  will  briefly  consider  the  main  divisions. 

Adeno-carcinoma. — This  is  characterized  by  its  origin  chiefly 
in  cysts  of  chronic  mastitis,  by  the  markedly  circumscribed 
character  of  the  growth,  the  bulky  local  tumor  often  produced, 
the  long  immunity  of  the  lymph  nodes,  the  relatively  favorable 
prognosis,  and  the  specific  structure.  But  certain  cases  are 
much  more  malignant,  and  produce  bulky  tumors  invading 
much  of  the  breast,  perforating  the  skin  as  fungous  masses, 
and  early  involving  the  lymphatics  in  various  directions. 
Everywhere  epithelium  predominates  over  stroma. 


58  CANCER 

The  gross  appearance,  transitional  types,  and  minute  struc- 
ture point  clearly  to  the  origin  of  these  tumors  from  the 
papillary  ingrowth  of  mammary  cysts.  From  the  study  of  the 
groups  of  tumor,  Ewing  concludes  that  the  lacteal  ducts  pro- 
duce most  of  the  low  papillary  and  glandular  adeno-carcinomas, 
with  cuboidal,  clear  cells,  while  the  sweat  glands  give  rise 
chiefly  to  papillary  and  villous  adeno-carcinomas,  with  cylindri- 
cal cells  of  acidophile  character. 

Duct-carcinoma. — Carcinoma  arising  in  the  interlobular  and 
large  ducts  produces  tumors  of  characteristic  gross  and  micro- 
scopical structure,  and  somewhat  peculiar  clinical  course.  The 
tumor  usually  begins  near  the  nipple  and  affects  the  central 
portions  of  the  gland,  or  it  may  first  appear  in  any  portion  of 
the  breast.  Eventually  it  tends  to  invade  the  entire  organ, 
with  marked  fibrosis  and  reduction  in  size.  In  the  more 
malignant  forms  the  organ  may  be  considerably  enlarged  by 
diffuse  growth,  in  which  case  the  typical  gross  features  may  be 
lost.  Very  extensive  involvement  of  the  skin  and  subcutaneous 
tissue,  extending  even  beyond  the  breasts  is  a  striking  feature  in 
some  cases.  The  structure  presents  marked  proliferation  of 
the  lining  cells,  first  of  the  larger,  then  of  the  smaller  ducts,  or 
vice  versa.  The  origin  of  this  form  of  mammary  carcinoma  has 
been  satisfactorily  traced  to  the  lining  cells  of  the  interlobular 
ducts. 

As  a  rule  the  cells  of  duct-carcinoma  are  clear,  and  as  they 
become  more  atypical,  the  cytoplasm  becomes  less  prominent. 

Acinar -carcinoma. — This  develops  in  the  malignant  trans- 
formation of  fibro-adenoma,  it  occurs  in  rare  cases  of  small 
alveolar-carcinoma,  and  it  produces  a  type  of  fibro-carcinoma. 
These  tumors  are  characterized  in  general  by  a  diffuse  growth 
and  lack  of  encapsulation,  by  absence  of  the  specific  gross 
features  of  many  duct  cancers,  and  by  a  structure  in  which  small 
alveoli  predominate,  while  the  cells  are  usually  small,  and  lack 
the  pavement  form  and  clear  cytoplasm  of  the  duct  epithelium. 
In  some  cases  of  productive  mastitis,  and  possibly  in  otherwise 
unaltered  breasts,  the  acinar  epithelium  may  give  rise  to  a 


HISTO-PATHOLOGY  OF  CANCER  59 

malignant  form  of  scirrhus,  or  fibro-carcinoma.  About  the 
unaltered  layer  and  the  interlobular  ducts  the  acini  become 
increased  in  number  and  break  up  into  many  small  groups  of 
atypical  cells,  with  hyperchromatic  nuclei.  The  connective 
tissue  is  much  increased  and  soon  becomes  fibrous,  while  the 
tumor  cells  are  compressed  into  narrow  rows  or  small  groups. 
Many  cases  of  primary  scirrhus  develop  in  this  manner,  and 
the  process  is  fully  malignant. 

Pagefs  Disease. — This  is  a  specific,  chronic,  progressive 
disease  of  the  epithelium  of  the  mammary  nipple  and  adjoining 
skin,  which  is  closely  related  to  and  almost  invariably  followed 
by  carcinoma.  Some  cases  appear  to  represent  an  extension 
of  duct-  or  sweat-gland  carcinoma  into  the  epidermis,  others  a 
primary  precancerous  affection,  limited  chiefly  or  exclusively 
to  the  epidermis. 

The  earliest  changes  have  been  located  in  the  squamous 
epithelium  of  the  nipple,  or  in  the  milk  ducts  below  the  nipple, 
but  it  is  doubtful  if  the  earliest  stages  of  the  process  have  been 
yet  observed.  In  the  epidermis  characteristic  "Paget  cells" 
appear  as  swollen,  rounded,  clear  staining,  hydropic  cells,  single 
or  in  groups,  with  hyper-chromatic  nuclei,  often  in  mitosis.  The 
Malpighian  layer  containing  these  cells  is  usually  thickened  and 
the  papillas  elongated:  the  corium  is  commonly  rich  in  plasma- 
cells.  There  is  still  much  discussion  in  regard  to  the  true 
nature  of  Paget's  disease,  whether  it  is  primary  or  secondary  to 
the  carcinoma  of  adenoid  growth,  which  is  apt  to  follow  it. 

As  in  all  cancer  the  lymphatic  system  plays  an  important 
part,  both  in  its  dissemination  in  the  breast  and  in  the  involve- 
ment of  other  organs.  The  permeation  theory  of  Handley 
has  become  pretty  widely  accepted,  mainly  for  the  extension  of 
the  disease  within  the  organ;  this  relates  to  a  growth  of  cancer 
cells  along  lymphatic  vessels,  rather  than  to  a  conveyance  of 
them  in  the  lymph  stream.  We  know,  however,  that  cancer  in 
every  location  spreads  by  continuity  of  tissue,  cancer  cells 
having,  as  it  were,  the  power  of  persuading  adjoining  cells  to 
take  on  the  same  morbid  action. 


60  CANCER 

The  chief  mode  of  extension  to  other  and  distant  parts  is 
undoubtedly  through  the  lymphatics  and  also  in  a  measure 
through  blood  vessels,  mainly  through  the  veins,  the  cancer  cells 
having  gained  access  to  the  latter  through  the  thoracic  duct, 
or  possibly  by  the  penetration  of  a  vein  by  the  disease.  This 
method  is  almost  exclusively  followed  in  the  highly  malignant 
tumors,  fibro-carcinoma,  acinar-carcinoma,  and  adeno-carci- 
noma. 

In  advanced  cancer  of  the  breast  almost  every  portion  of  the 
body  may  be  affected,  and  the  following  list  of  the  relative 
frequency  of  different  parts  affected  has  been  given,  Gross, 
Ewing:  lungs,  liver,  bones,  brain,  ovary,  opposite  breast,  dura 
mater,  kidneys,  retro-peritoneal  nodes,  uterus,  and  other 
organs.  The  bones  most  frequently  involved  are  the  sternum 
and  ribs,  femur,  vertebral  column,  cranium,  humerus,  and 
clavicle.  The  main  lymphatic  line  of  dissemination  is  that 
which  leads  through  the  sheaths  of  the  muscles  to  the  axillary 
region,  which  is  the  largest  and  drains  all  parts  of  the  gland. 
Another  set  of  lymphatic  vessels  passes  to  the  glands  of  the 
anterior  mediastinum,  and  others  pass  upward  over  the  clavicle 
and  invade  the  supraclavicular  glands,  while  still  others  stretch 
across  to  the  other  breast. 

Sarcoma. — While  conventionally  sarcoma  is  often  spoken 
of  as  cancer,  and  is  commonly  included  in  the  statistics  of 
cancer,  it  is  quite  a  different  disease,  histologically  as  well  as 
clinically,  from  carcinoma  as  just  presented.  Some  statistics 
place  its  frequency  at  about  14.5  per  cent  of  cases  of  malignant 
disease  but  it  is  probably  much  less.  It  is  apt  to  occur  at  a 
far  earlier  period  of  life,  and  malignant  tumors  occurring  before 
20  years  of  age  are  practically  all  sarcomas;  while  carcinoma  is 
very  rarely  seen  before  that  age,  although  sarcoma  may  also 
occur  much  later  in  life. 

The  subject  of  the  histology  of  sarcoma  is  rather  a  mixed  one, 
as  there  are  so  many  different  types,  according  to  the  tissues 
involved.  Thus,  Ewing  says:  "According  to  histogenesis 
sarcoma   may    be    classified    as   fibro-plastic,   angio-sarcoma, 


HISTO-PATHOLOGY  OF  CANCER  6 1 

chondro-sarcoma,  osteosarcoma,  lipo-sarcoma,  myo-sarcoma, 
myxo-sarcoma,  lympho-sarcoma,  and  glio-sarcoma."  It  would 
take  us  far  beyond  the  proper  limits  of  this  chapter,  and  be 
unnecessary  for  the  understanding  of  our  subject  to  attempt 
in  any  way  to  analyze  the  facts  concerning  all  the  manifesta- 
tions of  the  disease  to  which  the  name  of  sarcoma  is  attached. 
We  will,  therefore,  only  briefly  outline  the  general  character- 
istics of  the  sarcomatous  neoplasm  as  given  by  Ewing,  leaving 
until  later  the  consideration  of  its  development,  which  is 
undoubtedly  due  to  much  the  same  deranged  constitutional 
conditions  as  cause  carcinoma.  There  is,  however,  this  differ- 
ence between  these  two  forms  of  neoplastic  growths,  namely, 
that  sarcoma  seems  to  arise  from  single  or  brief  traumatic 
incidents,  while  in  carcinoma  the  cause  of  the  primary  location 
of  the  malignant  disease  in  any  particular  place  may  be  from 
repeated  or  long  continued  local  injury  or  excitation. 

Sarcoma  is  a  malignant  tumor  composed  of  cells  of  the 
connective  tissue  type.  Sarcomas  are  chiefly  histoid  tumors, 
that  is,  resembling  in  structure,  or  composed  of,  or  developed 
from  one  of  the  tissues  of  the  body.  In  general  the  structure 
of  sarcoma  presents  an  imperfect  development  of  the  tissue 
of  origin,  as  indicated  in  the  various  forms  of  the  disease  already 
mentioned:  its  cells  are  usually  larger  and  always  numerous. 
"It  seems  high  probable,"  says  Ewing,  "that  sarcomas,  like 
carcinomas,  arise  through  exaggerated  and  regenerative 
overgrowth  of  tissue  cells." 

While  in  many  cases  the  cells  of  origin  are  adult,  theoretical 
considerations  suggest  that  in  some  instances  they  are  embryo- 
nal. While  according  to  cell  form,  sarcomas  may  be  divided 
into  spindle-cell,  round-cell,  and  giant-cell  groups,  he  believes 
that  these  terms  convey  little  information,  and  unless  the 
tissue  of  origin  be  stated,  no  significant  diagnosis  has  been 
reached.  The  controlling  factor  in  the  structure  of  sarcoma  is 
found  in  the  natural  tendencies  of  the  cells  of  origin  to  reproduce 
the  mother  tissue. 

The  stroma  of  sarcoma  is  derived  from  remnants  of  pre- 


62  CANCER 

existing  tissue,  from  blood  vessels  appropriated  for  the  nutrition 
of  the  tumor,  or  new  formed  as  an  integral  part  of  the  neoplasm, 
and  from  the  specific  intercellular  substances  derived  from  the 
tumor-cells.  The  blood  vessels  form  the  most  important  part  of 
the  stroma,  and  are  of  various  forms  and  sources.  Such  vessels 
may  be  venous,  arterial,  or  capillary,  and  their  walls  are  composed 
of  adult  normal  cells.  As  the  tumor  develops  the  adventitia 
of  the  vessels  is  lost  in  the  stroma  of  the  neoplasm,  and  eventu- 
ally nothing  but  a  swollen  endothelial  cell  separates  the  blood 
current  from  tumor-tissue,  leading  to  interstitial  hemorrhage. 

Spindle-cell  sarcoma  is  the  most  common,  and  represents 
the  purest  form  of  fibro-plastic  neoplasm.  The  structure 
falls  into  two  main  classes  which  differ  also  in  their  clinical 
features:  i.  Small  and  2.  Large  spindle-cell  sarcoma.  The 
spindle-cells  of  either  type  resemble  fusiform  fibro-blasts. 
They  are  much  smaller  than  normal  fibro-blasts,  and  more 
densely  packed  in  the  smaller  cell  growths,  but  reach  very 
large  dimensions  and  are  loosely  arranged  in  the  large-cell 
type.  The  cytoplasm  is  granular,  opaque,  and  acidophile, 
the  nuclei  vesicular  and  provided  with  one  or  more  small 
nucleoli.  In  many  soft,  vascular  tumors  the  cells  are  poly- 
morphous, small  and  large  spindle,  polyhedral,  and  rounded 
cells  appearing  in  foci  or  throughout.  Such  growths  are  often 
called  round-cell  sarcoma,  but  a  true  round-cell  sarcoma  of 
fibro-blastic  origin  probably  does  not  occur. 

Round-cell  and  giant-cell  sarcoma  are  much  less  common, 
and  affect  deeper  organs.  In  the  stomach  they  are  reported 
as  constituting  about  1  per  cent  of  all  gastric  tumors,  and  have 
been  observed  in  the  oesophagus,  intestines,  uterus,  etc.  The 
most  important  aspect  of  sarcoma  is  probably  its  relation  to 
the  bones,  where  it  produces  great  ravages,  originating  in  the 
periosteum,  commonly  with  the  history  of  a  mechanical  injury. 
This  great  subject  can  hardly  be  well  considered  here. 

Sarcomas  in  general  have  very  few  lymphatics,  and  metas- 
tases are  not  as  common  as  in  carcinoma,  although  they  are 
observed   in   the   advanced   stage   of   most   sarcomas.     Their 


HISTO-PATHOLOGY  OF  CANCER  63 

extension  to  other  parts  is  mainly  through  the  blood  vessels 
and  through  fascial  planes,  along  vessels  and  nerves,  and 
directly  through  the  soft  tissues. 

ANAPLASIA 

This  term,  unlike  metaplasia,  has  a  specific  bearing  on  malig- 
nant tumors.  The  normal  parent  cells  give  rise  to  tumor-cells 
which  bear  some  relationship  to  the  former,  both  morphologic- 
ally and  physiologically.  Thus  sarcomata  which  arise  from  the 
chromatophiles  of  the  skin  consist  of  cells  which  can  produce 
melanin.  In  addition  to  resemblances  of  this  kind  there  are 
notable  differences;  and  all  alterations  which  confer  malignancy 
on  the  tumor-cells  such  as  unlimited  growth,  absence  of  all 
function,  abnormal  cell  division,  etc.  are  summed  up  by  von 
Hansemann  under  the  term  anaplasia.  One  of  the  most  signifi- 
cant of  these  is  the  tendency  to  degenerate,  and  here  the  terms 
anaplasia  and  metaplasia  maybe  confusing.  As  the  cell  loses  its 
differentiating  attributes  it  takes  on  an  independent  existence. 
In  cancer,  etc.  "every  cell  is  for  itself"  and  there  is  no  altruism 
or  commonwealth.  Anaplasia  means  "lessened  differentiation 
and  increased  power  of  independent  existence." 

The  term  heteroplasia  has  but  little  use  in  tumor  genesis  and 
it  may  readily  be  confused  with  heterotopia.  The  heteroplasias 
of  authors  correspond  to  apparent  heterotopias,  such  as  the  oc- 
currence of  islets  of  gastric  tissue  in  the  oesophagus;  these, since 
they  are  limited  to  certain  areas  of  the  body,  are  doubtless 
congenital. 

Other  terms  sometimes  found  in  connection  with  malignant 
tumor  growth  are  kataplasia,  alloplasia  and  dysplasia.  All  such 
terms  are  confusing,  often  overlap,  etc,  and  individually  have 
at  times  quite  unusual  meanings,  as  when  anaplasia  is  applied  to 
plastic  surgery,  dysplasia  to  a  congenital  malformation,  etc. 
Their  applicability  to  cancer  genesis  and  retrograde  changes 
seems  uncalled  for. 

THE  CANCER  CELL  AND  SOME  OF  ITS  PROPERTIES 

The  cancer  cell,  by  which  term  is  understood  the  aggregation 
of  cells  which  makes  up  the  morbid  growth,  may  be  studied 


64  CANCER 

from  a  number  of  angles.  These  include  the  histology  of  the 
cells  and  the  architecture  of  the  tumor,  the  chemical  composi- 
tion, the  dynamics  of  the  cells — their  mode  of  multiplication, 
the  action  on  the  surrounding  tissues,  and  the  reaction  of  the 
environment  to  the  cancer  process — the  metabolism  of  the 
cancer  as  distinguished  from  that  of  the  individual  as  a  whole, 
during  the  active  period  of  growth;  also  the  regressive  changes, 
and  finally  the  products  of  the  cells  from  first  to  last,  both 
during  the  active  period  and  after  secondary  changes  have 
set  in. 

The  subjects  of  anatomical  structure  and  cell  multiplication 
may  be  studied  to  advantage  jointly.  It  is  not  necessary  to 
consider  such  aspects  as  are  fully  covered  in  textbooks  on  cancer. 
Of  the  isolated  cancer  cell  we  know  but  little,  and  the  expression 
is  commonly  found  that  a  single  cancer  cell  presents  nothing  to 
characterize  it  or  to  distinguish  it  from  normal  epithelial  cells, 
except  for  a  certain  biological  misbehavior.  It  is  claimed  that 
while  the  normal  cell  swells  up  in  saline  solution  the  cancer  cell 
shrinks,  which  claim,  if  true,  appears  to  point  to  some  physico- 
chemical  peculiarity  involving  osmosis.  It  is  also  claimed 
that  a  cancer  cell  dissolves  in  the  serum  of  its  host,  but  not  in 
the  serum  of  a  sound  subject.  This  fact  appears  to  point  to  the 
formation  of  a  lysin  in  the  blood  of  the  patient.  Such  facts,  if 
facts  they  are,  are  of  the  utmost  interest,  but  do  not  seem  to 
have  led  to  any  practical  conclusions  or  to  have  opened  up  any 
new  field  of  research.  It  may  be  added  that  cancer  cells  can 
be  transplanted  in  animals  and  give  rise  to  tumors  of  the  same 
sort,  while  normal  epithelium  cannot  act  thus,  but  grows  nor- 
mally, as  in  skin  grafts. 

When  cancer  cells  are  considered  in  the  aggregate  they  present 
a  certain  absence  of  standardisation  or  departure  from  the  nor- 
mal, which  has  been  termed  anaplasia  and  which  is  elsewhere 
considered  because  of  its  theoretical  character;  for  this  chapter 
deals  as  far  as  possible  with  facts. 

The  next  subject  for  consideration  is  the  segmentation  of  the 
cell,  that  is  as  to  its  method  of  multiplication.     Much  has  been 


HISTO-PATHOLOGY  OF  CANCER  65 

written  of  karyokinesis  and  mitotic  changes  in  cancer  cells,  but 
apparently  these  may  be  summed  up  in  a  few  words;  dissocia- 
tion of  the  chromatin  in  the  two  nuclei  which  result  from  seg- 
mentation, so  that  one  contains  much  more  chromatin  than  the 
other;  and  reduced  mitosis,  such  as  is  seen  in  other  pathological 
processes;  also  multipolar  mitosis  and  the  formation  of  giant- 
cells.  The  practical  significance  of  these  departures  has  not 
thus  far  been  significant,  either  for  practical  ends  or  for  opening 
up  new  lines  in  research.  It  has  been  claimed,  for  example,  in 
the  Mayo  laboratory,  that  in  the  division  of  a  cancer  or  cancer- 
genetic  cell  a  new  cell  is  formed  without  a  chromosome,  the 
latter  becoming  thus  an  autocratic  or  parasitic  cell;  but  others 
hold  that  the  nuclei  of  different  cancer-genetic  cells  conjugate 
to  produce  new  individual  cells  which  are  cancerous.  These 
two  views  may  be  made  to  coincide  without  much  effort,  but  the 
speculative  element  enters  strongly  into  the  subject  of  cancer- 
genetic  cells,  which  are  presumably  normal  until  altered  by  some 
force  from  without.  Of  these  beginnings  we  know  nothing.  It 
may  be  that  one  cancer  cell  can  corrupt  normal  cells  and  compel 
them  to  share  its  behavior,  or  that  an  entire  breed  of  cancer 
cells  may  be  generated  synchronously  from  normal  cells.  The 
opinion  at  present  seems  to  be  in  favor  of  the  normal  character 
of  the  cells  which  give  rise  to  cancer. 

To  pass  from  speculation  to  fact  there  is  every  reason  to  be- 
lieve that  cancer  cells  may  lie  fallow  in  the  tissues  until  roused 
to  activity  by  some  unknown  force.  This  has  been  seen  for 
example  in  the  margin  of  a  gastric  ulcer.  But  a  cancer  which  is 
inactive,  presenting  only  the  histological  appearance  of  the  dis- 
ease, may  not  be  a  cancer  in  a  clinical  sense,  as  in  so-called 
benign  cancer  of  the  appendix. 

The  cancer  cell  is  technically  a  modified  epithelial  cell  which 
resembles  closely  the  epithelial  cells  from  which  it  springs,  but 
which  tends  to  depart  from  a  standard  model,  giving  rise  to  the 
expression  anaplasia  already  mentioned.  To  call  it  an  embry- 
onal cell  involves  a  contradiction,  for  it  is  a  property  of  embry- 
onal cells  to  develop  into  finished  and  adult  cells,  and  this  is  not 


66  CANCER 

seen  in  cancer  but  rather  in  teratomata.  Its  tendencies  are  in 
fact  to  regression  and  degeneration,  as  will  be  shown  later, 
all  such  retrograde  alterations  having  nothing  in  common  with 
so-called  anaplasia. 

The  predisposing  and  exciting  factors  in  the  genesis  of  cancer 
will  be  discussed  in  full  elsewhere.  It  seems  enough  to  state 
in  this  connection  that  nothing  can  run  wild  in  nature  unless 
some  natural  check  is  withdrawn,  and  that  a  study  of  what 
inhibits  cancer  growth  in  the  subject  who  escapes  the  disease 
should  be  as  profitable  as  any  one  of  the  exciting  causes — for 
the  rapid  diffusion  of  cancer  today  argues  that  the  protection 
enjoyed  for  centuries  is  being  withdrawn.  Since  cancer  develops 
from  normal  epithelial  cells  which  have  a  characteristic  arrange- 
ment, it  is  commonly  said  that  the  first  step  in  the  formation  of  a 
cancer  is  a  penetration  of  cells  through  the  basement  membrane, 
or  other  limiting  connective  tissue  formation.  Aside  from  this, 
cancer  also  develops  along  the  lines  of  benign  epithelial  growths 
— papilloma  and  adenoma — this  being  true  of  cancer  of  the 
skin  and  mucosas.  There  is  either  an  outgrowth  or  an  infold- 
ing of  the  epithelium,  in  the  latter  case  ending  in  infiltration  of 
the  subepithelial  connective  tissue. 

It  was  formerly  taught  that  the  cancer  cell  secreted  a  histoly- 
tic  substance  which  to  some  extent  dissolved  the  surrounding 
tissues;  but  at  the  present  day  we  find  this  procedure  reserved 
for  tumors  made  up  of  decidual  cells.  The  subject  of  locomo- 
tive properties  of  cancer  cells  is  no  longer  emphasized  today, 
save  in  connection  with  retrograde  metastases  in  the  lymph- 
tracts,  which  make  it  necessary  to  assume  that  the  cancer  cell 
can  force  itself  against  the  lymph-current.  But  even  this  might 
be  explained  by  ordinary  vis  a  tergo,  and  the  latter  seems  to  be 
the  only  mechanism  understood  to  exist  today,  the  energy  of 
cell  growth  being  sufficient  to  explain  the  invasion  of  the  neigh- 
boring tissues.  Cancer  cells  select  the  path  of  least  resistance, 
which  explains  why  they  first  enter  the  interstices  of  the  sur- 
rounding cellular  tissue  and  the  preformed  lymph  channels. 
But  it  is  difficult  to  understand  the  different  behavior  of  cancer 


HISTO-PATHOLOGY  OF  CANCER  67 

and  sarcoma  when  these  tumors  come  in  contact  with  bone,  as 
at  the  base  of  the  skull :  for  while  the  sarcoma  wears  away  the 
bone  mechanically,  cancer  penetrates  into  the  latter,  infecting 
and  softening  it.  This  behavior  once  more  suggests  either  a 
special  penetrating  force  or  the  formation  of  enzymes  which  can 
attack  the  connective  tissue. 

According  to  the  Mayos  there  is  in  incipient  cancer  the  forma- 
tion of  an  acid-reacting  fluid  which  tends  to  spread  through  the 
body  and  is  a  forerunner  of  cachexia.  This  statement  is  not 
readily  harmonized  with  the  claim  that  in  the  latter  condition 
the  alkalinity  of  the  body  has  become  increased.  An  initial 
acidity  must  give  way  eventually  to  an  opposite  state.  But 
these  subjects  belong  properly  under  the  chemistry  of  cancer. 

We  next  have  to  consider  the  action  of  cancer  on  the  connec- 
tive tissues  and  the  reaction  of  the  latter  to  the  cancer  mass. 
The  latter  contains  a  varying  amount  of  stroma,  none  of  which 
it  forms  itself.  In  sarcoma,  where  the  stroma  is  always  slight, 
it  may  be  formed  from  the  tumor  cells,  but  this  is  not  the  case 
with  carcinoma.  The  cells  of  the  latter,  as  stated,  invade  in- 
terstices and  move  along  the  lymph  channels  from  the  very 
start,  and  then,  according  as  defense  reaction  does  or  does  not 
develop,  we  see  opposite  types  of  cancer  arise  with  all  gradations 
between. 

As  it  infiltrates  its  periphery,  cancer  at  the  same  time  compels 
the  latter  to  deliver  tribute  in  the  shape  of  a  stroma  of  support- 
ing tissue  containing  blood  vessels.  This  is  the  chief  action  of 
the  growth.  When  there  is  a  pronounced  reaction  this  is 
practically  inflammatory  in  character,  and  must  be  inter- 
preted in  part  as  a  defense  reaction.  It  is  in  evidence  between 
cell  clusters,  as  well  as  in  the  circumference  of  the  new  growth, 
and  not  only  walls  off  the  surrounding  tissues  like  a  coffer  dam, 
but,  since  it  may  manifest  contractive  properties,  it  compresses 
the  tumor  cells  both  from  within  and  without,  and  doubtless 
obliterates  or  contracts  the  lymph  spaces  and  thus  prevents 
metastases.  So  intense  is  this  reaction  in  special  cases  that  the 
new  connective  cells  have  ended  in  the  formation  of  sarcoma- 


68  CANCER 

tous  tissue.  The  barrier  formed  doubtless  bears  some  analogy 
to  that  which  develops  after  removal  of  a  cancer  by  the  cautery, 
or  the  use  of  caustic  pastes;  it  is  also  claimed  that  the  beneficial 
effects  of  irradiation  are  brought  about  by  increased  production 
of  stroma.  Where  the  reaction  is  slight  or  absent  we  have 
the  so-called  soft  or  medullary  cancer,  which  is  now  admitted 
to  present  a  certain  amount  of  stroma,  this  differentiating  it 
largely  from  rapidly  growing  sarcoma.  But  in  soft  cancer  no 
"cofferdam" — to  quote  Murphy — forms,  and  infiltration  and 
metastases  have  no  natural  check. 

In  this  general  outline  of  cancer  the  cutaneous  form  is  not 
necessarily  included,  owing  to  its  lower  malignancy  and  clinical 
pecularities,  which  tend  to  make  of  it  more  of  a  surgical  affection; 
this  form  of  growth  has  not  shown  the  increased  frequency 
and  mortality  which  is  exhibited  by  the  mammary  uterine, 
gastric,  buccal  and  other  forms.  Again  in  cutaneous  epithe- 
lioma, although  a  predisposition  is  necessary,  the  exciting  cause 
is  usually  in  evidence  to  a  much  greater  degree  than  in  other 
cancers. 

In  regard  to  the  defense  reaction  on  the  part  of  the  connective 
tissue,  some  doubt  exists  as  to  the  formation  of  the  almost 
cartilage-like  substance  produced  in  extreme  forms  of  scirrhous 
cancer.  This  sort  of  reaction  is  not  seen  under  any  other 
circumstances,  hence,  it  may  be  well  to  ascribe  it  to  the  action 
of  the  tumor,  rather  than  the  reaction  of  the  sound  tissues. 
It  has  been  assumed  that  a  special  secretion  of  the  cancer  cell 
can  generate  this  sclerogenic  tissue,  and  it  has  received  the 
name  of  "desmoplastic  secretion."  According  to  Murphy 
loose  cellular  tissue,  filled  with  adipose,  is  unable  to  form  a  pro- 
tective barrier.  The  relations  of  cancer  to  inflammation  are 
discussed  elsewhere  but  it  may  be  remarked  here  that  in  some 
stromas  the  process  is  purely  inflammatory,  while  in  others 
this  feature  is  not  in  evidence.  We  may  infer  that  in  inflamma- 
tory stroma  there  will  be  some  contraction  with  compression 
of  cancer  cell  groups,  as  already  suggested. 

The  relations  between  the  parenchyma  and  stroma  in  cancer 


HISTO-PATHOLOGY  OF  CANCER  69 

tissue  may  differ  notably.  In  some  cases  of  so-called  organoid 
cancer  the  correlation  may  approximate  that  of  normal  glands, 
etc.  In  scirrhus,  the  stroma  may  greatly  preponderate  over  the 
parenchyma,  while  at  the  other  extreme  the  tissue  approaches 
the  histioid  type,  in  which  the  cellular  element  greatly  pre- 
ponderates over  the  stroma.  The  supply  of  blood  vessels  is 
at  best  very  poor,  with  resulting  sluggishness  of  the  circulation, 
and  since  the  stroma  supports  the  vessels,  cancer  which  is 
deficient  in  this  respect  is  prone  to  necrotic  changes.  Aside 
from  this  factor  there  is  another  which  has  the  same  result — the 
compression  of  the  central  cells  by  the  rapid  accumulation  of 
peripheral  cells. 

In  reviewing  the  histo-pathology  of  carcinoma  and  sarcoma 
we  are  struck  with  the  similarity  in  the  accepted  descriptions 
of  the  changes  which  take  place  in  the  cells  which  constitute 
cancer  in  any  and  every  region.  In  all  of  them  there  is  an 
irregular,  atypical,  abnormal  development,  which  results  in 
a  malignity  tending  to  perpetuate  itself  and  extend,  until,  if 
not  checked,  the  process  destroys  life. 

The  reason  for  this  malignant  action,  which  must  first  start 
in  some  individual  cell  or  cells,  has  never  been  explained,  and 
it  is  universally  stated  that  we  do  not  know  the  cause  of  cancer. 
But  there  is  no  mystery  in  the  disease,  and  the  real  cancer 
problem  is  cleared  up  when  we  study  the  bio-chemistry  of  the 
disease,  as  will  appear  in  other  chapters.  Elsewhere,  also, 
there  are  presented  the  negative  results  of  laboratory,  experi- 
mental, and  clinical  research,  and  how  one  is  forced  by  them, 
and  by  many  positive  reasons,  to  turn  to  faulty  metabolism 
for  the  explanation  of  the  erroneous  actions  of  the  cells.  Ewing 
and  others  repeatedly  mention  "atypical,  over-nourished  cells" 
in  connection  with  cancer  in  many  locations.  The  fact  that  in 
practically  every  part  of  the  human  frame  where  epidermic 
cells  are  found,  there  is  a  liability  for  them  to  become  diseased, 
either  primarily  or  secondarily,  would  seem  to  point  to  some 
common  cause  or  agent  capable  of  reaching  every  cell  in  the 


70  CANCER 

body,  and  this,  of  course,  is  found  in  the  blood,  which  we  will 
later  see  is  profoundly  affected  in  these  diseases.  This  has  been 
studied  mainly  as  to  its  cellular  constituents,  but  very  little 
in  regard  to  its  plasma,  in  which  the  cells  are  bathed,  and  from 
which  they  receive  their  right  or  wrong  pabulum. 

That  no  specific  changes  in  the  blood  which  are  pathogno- 
monic of  cancer  have  as  yet  been  determined,  is  not  singular  or 
negatively  conclusive.  How  little  do  we  know  in  the  matter 
of  the  absolute  blood  changes  belonging  to  many  diseased 
conditions,  which  are  treated  with  more  or  less  success,  osteo- 
malacia, ricketts,  arthritis  deformans,  arterio-sclerosis,  or  many 
affections  non-inflammatory  or  non-infective.  Who  can  even 
say  what  is  the  active  resisting  power  by  which  the  very 
large  proportion  of  the  multitudes  in  whom  the  tubercle  bacillus 
finds  lodgment,  escape  serious  results  from  the  same?  If 
the  erratic,  malignant  behaviour  of  the  originally  normal  body 
cells,  resulting  in  cancer,  does  not  come  from  erroneous  nutri- 
tion, as  accomplished  by  anabolism  and  catabolism,  which  will 
be  discussed  later,  what  other  possible  explanation  can  be 
offered? 


CHAPTER  V 
BIO-CHEMISTRY  OF  CANCER 

Much  labor  has  been  expended  in  endeavoring  to  discover  in 
tumor  tissue  the  secret  of  malignancy,  but  thus  far  all  efforts 
have  failed  to  identify  the  presence  of  any  specific  morbid 
substance  which  answers  all  requirements. 

Ewing  has  given  a  chapter  upon  this  subject,  and  while  it 
does  not  appear  to  lead  to  any  striking  advance  in  our  practical 
knowledge  of  the  nature  of  cancer,  the  interesting  and  valuable 
researches  recorded  warrant  their  presentation. 

"Constitution  of  Tumor  Proteins. — The  conception  that  tumor 
proteins  must  differ  in  essential  respects  from  those  of  normal 
tissues  has  not  been  demonstrated  by  chemical  methods.  The 
nature  of  the  problem  involved  appears  to  have  presented  itself 
in  different  forms  in  the  minds  of  investigators  who  have  at- 
tacked the  problem. 

"A  different  distribution  of  normal  proteins  from  that  of 
normal  tissues  has  been  demonstrated  in  tumor  tissues  by  Petry, 
Wolff,  and  Beebe,  who  found  a  higher  content  in  nucleo-protein, 
more  uncoagulable  protein,  and  less  globulin  and  albumen.  It 
is  probable  that  these  results  depend  on  the  over-growth  of 
cell  nuclei,  degenerative  and  autolytic  processes,  and  cedema. 
Nucleohiston  is  present  only  in  lymph-nodes  among  normal 
tissues  and  its  presence  in  lymphatic  metastases  of  tumors  orig- 
inally free  from  this  protein,  indicates  that  metastatic  tumors 
receive  chemical  impress  from  the  tissue  in  which  they  are  grow- 
ing. Although  nucleohiston  is  absent  in  primary  carcinoma  of 
the  breast  and  in  the  testis,  Beebe  found  this  substance  in 
lymph-node  metastases  of  mammary  cancer,  and  Bang  in  the 
lymphatic  metastases  of  testicular  carcinoma.  Nucleohiston 
gives  a  preciptiate  when  calcium  chloride  is  added  to  a  watery 
solution  of  the  tumor. 

71 


72  CANCER 

"  Direct  chemical  analysis  of  the  split  products  of  cancer  pro- 
teins by  Wolff  yielded  a  high  proportion  (35  per  cent)  of  gluta- 
minic  acid,  while  Bergell  and  Dorpinghaus  found  excess  of 
alanin,  phenylalanin,  asparaginic  acid,  and  diamino  acids.  Yet 
these  results  conflicted  with  those  of  Petry,  Neuberg,  and 
Beebe. 

"Resistance  to  peptic,  and  susceptibility  to  tryptic  digestion, 
was  said  by  Blumenthal  and  Wolff  to  distinguish  tumor  from 
normal  tissues.  Yet  their  results  were  not  uniform  and  were 
probably  determined  by  the  increased  amount  of  nucleo-pro- 
teid  in  some  of  the  tumors. 

"Excess  of  potassium  and  defiency  in  calcium  in  rapidly 
growing  tumors,  free  from  necrosis,  and  the  opposite  relations  in 
slowly  growing  or  old  necrotic  tumors,  have  been  demonstrated 
by  Beebe  and  by  Clowes. 

"Pentose  was  greatly  increased  in  fibro-carcinoma  of  the 
breast,  in  comparison  with  the  amount  in  the  normal  breast, 
in  cases  studied  by  Beebe  and  Shaffer.  These  authors  also 
found  that  the  pentose  content  in  different  tumors  varied,  and 
bore  no  relation  to  the  nucleoprotein  or  to  the  presence  of 
degeneration. 

"Lactic  acid  appears  in  tumors,  according  to  Fulci,  in  consid- 
erable quantities.  It  is  more  abundant  in  epithelial  than  in 
connective  tissue  growths,  and  increases  in  the  more  malignant, 
actively  growing  tumors.  Its  formation  is  dependent  on  meta- 
bolic activity  of  the  tumor-cells,  its  source  is  the  blood  carbo- 
hydrates and  possibly  the  proteins.  It  appears  to  have  no 
relation  to  cachexia. 

"Of  the  total  phosphorus  of  the  normal  liver,  B.  Wolter 
found  28.68  per  cent  as  phosphatid  phosphorus;  in  the  tumor- 
free  portions  of  the  liver  with  primary  carcinoma  22.04  Per  cent, 
and  in  the  tumor  nodules,  16.28  per  cent  while  the  protein 
phosphorus  in  the  same  materials  ran  20  per  cent,  25.5  per  cent, 
and  26.70  per  cent.  In  0.0634  gms.  of  dried-tumor  substance 
he  found  1.40  per  cent  of  cholesterin. 

"Tryptophan    was  markedly   increased   in    an    epidermoid 


BIO-CHEMISTRY   OF   CANCER  73 

carcinoma  of  the  skin,  and  in  an  hepatic  carcinoma,  over  the 
proprotions  found  in  a  normal  skin  and  liver,  in  cases  studied 
by  Fasal,  but  this  substance  was  absent  in  fibro-carcinoma. 

"Fats. — The  chemistry  of  tumor  fats  has  been  studied  exten- 
sively in  renal  and  adrenal  tumors.  In  general  it  appears  from 
Bossart's  work  that  actively  growing  tumors,  free  from  degenera- 
tion, contain  little  fat  and  much  lecithin,  while  with  degenera- 
tion and  necrosis  free  fats  replace  lecithin. 

"Purin  bodies  were  found  by  Wells  and  Long  in  about  the 
same  form  and  amount  as  in  normal  tissue,  and  less  abundantly 
than  the  nuclear  content  would  suggest.  The  purin  enzymes 
were  also  identical  with  those  of  normal  tissues,  guanase  being 
constantly  present,  and  adenase  absent. 

"The  delicate  methods  of  immunological  studies  indicate  that 
there  are  biological  differences  between  certain  tumor-tissues, 
which  are  probably  based  on  chemical  distinctions,  but  the 
results  obtained  in  this  field  are  not  decisive.  Following 
Michaelis'  failure  to  produce  specific  immune  bodies  against 
mouse  cells,  Beebe,  working  with  purified  nucleoproteids  of  a 
leukemic  spleen,  produced  a  serum  which  agglutinated  and 
emulsified  cells  of  the  spleen  and  those  of  a  lympho-sarcoma,  but 
acted  feebly  and  only  in  strong  concentration  on  cells  and 
nucleoproteids  of  normal  spleen  and  other  tissues,  as  well  as  of 
cancer  and  spindle-cell  sarcoma. 

"Tumor  Ferments. — The  study  of  special  ferments  in  tumors 
by  Buxton  and  Shaffer  demonstrated  no  distinct  difference  in 
quantity  or  quality  from  equivalent  normal  tissues.  Weil, 
using  the  viscosimeter  found  more  proteolytic  activity  in  certain 
cellular  tumors  than  in  normal  tissues,  but  was  not  prepared  to 
say  that  the  difference  did  not  depend  on  leucocytes.  Aberhal- 
den  however,  concluded  that  extracts  of  tumor-tissue  and  those 
of  normal  tissue  split  certain  polypetids  in  a  different  manner. 
Extracts  of  normal  mouse  liver  cleave  certain  polypeptids  slowly, 
while  those  of  mouse  tumors  act  much  more  quickly.  In  com- 
paring the  extracts  of  mouse  and  human  tumors  with  those  of 
normal  tissues,  he  found  differences  in  the  split  products  of  the 


74  CANCER 

proteins  after  the  action  of  these  ferments.  Comparing  the 
peptolytic  action  of  normal  and  tumor-tissue  from  lower  ani- 
mals on  peptone,  Abderhalden  and  Medigreceanu  found  occa- 
sional but  no  striking  differences. 

"Autolysis  is  often  observed  to  proceed  more  rapidly  in 
certain  tumor  tissues  than  in  normal  tissues,  but  it  is  probable 
that  all  such  differences  depend  on  the  more  cellular  character, 
and  presence  of  degenerating  tissue,  oedema,  leucocytes,  and 
bacteria.  It  is  extremely  difficult  to  obtain  normal  tissue 
which  may  safely  be  compared  with  tumor-tissue  in  this  respect. 

"The  increased  activity  of  autolysis  is  well  illustrated  in 
Yoshimoto's  experiments,  in  which  an  hepatic  carcinoma 
yielded  7.2  gms.  of  nitrogen  in  the  split  products,  as  compared 
with  4.8  gms.  in  equivalent  units  of  normal  liver.  With  a  mam- 
mary carcinoma  the  difference  was  even  greater.  In  the  tumor 
autolysate  purin  nitrogen  was  reduced,  while  that  of  diamino- 
acids,  peptone,  and  ammonia  was  increased  in  proportion. 

"It  is  commonly  believed,  on  the  basis  of  Jacoby's  experi- 
ments, that  autolytic  ferments  have  a  high  degree  of  specificity 
for  the  proteins  of  the  organs  in  which  the  ferments  are  found. 
Blumenthal  and  Wolff  have  reported  that  when  measured 
amounts  of  tumor-tissue  and  of  normal  tissue  are  autolized 
separately  in  one  series,  and  conjointly  in  another  the  autolysis 
is  always  greater  in  the  conjoined  series.  They  conclude  that 
the  tumor  ferments  attack  the  normal  tissues  and  exhibit  a 
heterolytic  property.  On  this  basis  rests  the  claim  that  infil- 
trative growth  and  cachexia  depend  on  the  heterolytic  activities 
of  the  tumor  ferments.  Baer  and  Ettinger  demonstrated  a 
proteolytic  activity  in  cancerous  ascitic  fluid,  which  failed  to 
appear  with  ascitic  fluid  from  other  sources,  but  Kepinow,  and 
Hess  and  Saxl  were  unable  to  verify  any  of  these  observations. 
The  possible  presence  of  bacteria,  necrosis,  or  post-mortem 
decomposition  has  apparently  not  been  considered,  although 
Neuberg  has  subsequently  denied  that  bacteria  or  leucocytes 
have  any  influence  on  the  results. 

"The    milky    character    of    carcinomatous    ascitic    fluid    is 


BIO-CHEMISTRY   OF   CANCER  75 

ascribed  by  Wolff  to  the  presence  of  chlorestin-acid-ester, 
combined  with  euglobulin.  In  a  series  of  cancerous  and  other 
ascitic  fluids  Weil  demonstrated  occasional  but  inconstant 
hemolytic  and  hemaglutinative  properties,  abundance  of 
complement  in  two  cancer  cases,  and  some  antitryptic  action, 
but  no  constant  distinction  between  the  cancerous  and  non- 
cancerous fluids.  Signs  of  active  autolysis  in  a  peritoneal 
exudate,  accompanying  ovarian  carcinoma,  are  reported  by 
Umber,  who  found  increase  in  non-coagulable  nitrogen, 
albumose,  leucin,  and  tyrosin.  Eppinger  reports  similar 
findings.  In  a  bloody  cancerous  exudate  K.  Wiener  demon- 
strated an  ereptic  ferment,  but  any  tryptic  ferment  present  was 
masked  by  the  blood.  In  this  fluid  were  traces  of  histidin  and 
arginin. 

"J.  W.  Vaughan  has  obtained  a  striking  relation  between 
anaphylactic  sensibility  of  guinea  pigs  inoculated  with  tumor 
residue  and  the  lymphocytosis  excited  by  the  inoculation. 
Animals  receiving  the  water-soluble  residue  of  cancer  cells, 
after  their  extraction  with  alkalized  alcohol,  or  a  vaccine  of 
tumor-cell  emulsion,  after  extraction  with  alcohol,  showed  in 
many  cases  very  high  lymphocytosis,  and  in  such  sensitized 
animals  anaphylactic  death  was  readily  produced.  The  sensi- 
tization was  quite  transitory,  lasting  only  during  the  4  to  10 
hour  period  of  lymphocytosis,  and  the  author  interprets  the 
result  as  depending  on  the  action  of  lymphocytic  ferments  on 
the  tumor  cells. 

''Wasserman  Reaction  in  Cancer. — The  results  obtained  with 
the  Wasserman  reaction  in  cancer  patients  varied  very  widely. 
Caan  secured  positive  reactions  in  41  per  cent  of  85  cases;  6  out 
of  7  lip  carcinomas,  in  9  per  cent  of  breast  tumors,  and  in  17 
per  cent  of  gastro-enteric  tumors.  All  of  these  cases  were 
free  from  clinical  signs  of  syphilis.  A  Foerster  secured  36 
negatives  in  37  cases,  and  Noguchi  38  in  39,  while  F.  J.  Fox 
reports  5  positive  in  210  cases  of  cancer.  Positive  reactions  in 
patients  with  cerebral  tumors,  free  from  syphilis,  appear  to  be 
not  uncommon  (Cohn). 


76  CANCER 

"  Antitryptic  Power  of  the  Blood. — Blood  serum  has  long  been 
known  to  inhibit  the  action  of  certain  ferments.  Brieger  and 
Trebing  first  found  that  the  serum  of  cancer  patients  inhibits 
very  markedly  the  action  of  trypsin.  Using  various  technical 
methods,  these  authors,  followed  by  Bergman  and  Meyer, 
Herzfeld,  Roche,  and  others,  showed  that  in  about  90  per  cent 
of  cancers  there  was  a  marked  increase  in  the  antitryptic 
power  of  the  blood  serum  but  that  considerable  increase  occured 
also  in  many  other  diseases,  especially  in  those  attended  with 
leucocytosis  (Weins,  Schlect).  Weil  by  an  exact  quantative 
method  determined  that  the  "antitrypsin"  is  increased  in  some 
cancer  cases  beyond  that  observed  in  any  other  diseases,  while 
in  other  cases  it  failed  to  fall  as  low  as  the  ratio  observed  in 
other  diseases.  All  authors  agree  that  the  failure  of  an  increase 
is  rather  strong  evidence  against  the  existence  of  established 
malignant  disease.  Brieger  regarded  the  phenomenon  as  a 
sign  of  cachexia  and  an  immunity  reaction  against  excessive 
amounts  of  proteolytic  ferments  derived  from  tumor  cells. 
Wiens  and  Schlecht  trace  a  close  connection  with  leucocytosis. 
Weil  points  out  that  the  exact  nature  of  the  inhibiting  sub- 
stance is  undetermined,  and  that  no  specific  relation  to  trypsin 
need  necessarily  exist,  since  blood  serum  also  inhibits  saponin. 
Among  57  cases  of  cancer  and  3  of  sarcoma  S.  M.  Lewin  found 
much  increased  antitryptic  power  in  57.  He  could  not  refer 
the  antiferment  action  to  leucocytes,  but  attributed  it  to  a 
reaction  to  proteolytic  ferments  discharged  into  the  blood  from 
degenerating  tumor  tissue. 

"Stammler's  Reaction. — Most  tumor  extracts  exhibit  a 
slight  or  distinct  opalescence.  Stammler  observed  that  the 
addition  of  cancer  serum  clears  up  this  opalescence,  with  the 
formation  of  a  slight  precipitate,  while  most  normal  sera  fail  to 
act  in  this  manner. 

"Ransohoff's  Test. — RansohofI  observed  that  the  injection  of 
3-5  c.c.  of  blood  serum  from  cancer  patients  in  guinea  pigs, 
which  had  previously  been  sensitized  by  1  c.c.  of  such  sera, 
caused  none  or  very  weak  anaphylactic  reaction,  while  normal 


BIO-CHEMISTRY   OF   CANCER  77 

human  serum  produced  the  usual  violent  reaction.  Since  the 
same  immunity  followed  sensitization  by  tumor  extract,  he 
concluded  that  the  immunizing  substance  of  the  serum  was 
derived  from  the  tumor.  In  a  series  of  50  cancer  cases  92  per 
cent  gave  a  positive  reaction,  while  the  test  was  always  negative 
in  other  conditions." 

We  may  now  discuss  the  chemical  composition  and  the 
metabolism  of  the  cancer  cell.  Individual  analyses  have  shown 
a  great  variability  in  the  kind  of  tissue-protein  found  in  the 
cancer  cell,  one  or  more  members  of  the  amino-acid  group  being 
present  perhaps  in  great  excess.  But  if  we  pursue  the  subject 
further  there  is  a  fair  amount  of  agreement  between  the  proteins 
of  cancer  and  normal  proteins.  There  is  no  constantly  present 
fact  to  stand  out  like  the  high  percentage  of  lipoids  in  hyper- 
nephroma. Variations  depend  on  a  number  of  factors  such  as 
the  proteins  in  the  tissue  from  which  the  growth  arises,  the 
age  of  the  cancer — for  in  the  older  ones  autolytic  products  are 
added  to  those  of  ordinary  metabolism,  etc.  As  far  as  possible 
we  are  writing  of  young  and  rapidly  growing  cancer  cells.  Of 
fresh  cancer  cells  we  only  know  from  experiments  in  vitro  that 
amino-acids  are  excreted  in  double  the  amount  found  in  ordinary 
tissues;  this  find  apparently  explains  the  presence  of  the  acid 
medium  said  to  occur  in  the  field  of  proliferation.  Another 
reason  for  different  results  in  protein  analysis  is  said  to  be  the 
retention  of  this  product  in  the  veins,  owing  to  sluggish  cir- 
culation. In  young  cancer  cells  the  production  of  katabolic 
substances  is  too  slight  to  be  readily  appreciable  by  ordinary 
tests,  so  that  considerable  amounts  of  amino-acids,  along  with 
proteoses,  speak  for  autolysis.  The  metabolism  of  cancer  per 
se  must  not  be  confounded  with  the  metabolism  of  the  indi- 
vidual, to  be  studied  later,  for  the  latter  is  studied  through  the 
urine,  while  even  the  most  delicate  tests  of  the  urine  would 
give  no  idea  of  the  metabolism  of  the  tumor  itself,  and  the 
same  is  possibly  true  of  blood  studies.  Few  facts  under  organic 
chemistry  have  any  practical  bearing.  Accumulation  of 
glycogen  apparently  signifies  only  the  filling  of  a  void,  as  seen 


78  CANCER 

in  deposits  of  fat  in  cellular  tissue.  Of  possible  significance  is 
the  increase  of  cholesterol,  to  be  discussed  later.  Cancer  pro- 
tein is  attacked  by  trypsin  while  normal  tissues  are  practically 
immune.  It  is  commonly  stated  that  cancer  cells  exhibit 
striking  efficiency  in  the  utilization  of  nitrogen  for  building 
purposes.  They  contain  only  about  half  the  amount  found  in 
ordinary  epithelium  yet  make  it  answer.  This  fact  should  be 
contrasted  with  another — the  double  production  of  katabolic 
amino-acid  by  cancer  cells.  Of  great  importance  is  the  fact 
that  the  water  content  of  rapidly  growing  cancer  cells  is  high. 
In  general  all  statements  as  to  increase  of  nucleins,  purin  bodies, 
and  various  amino-acids  should  be  rejected  as  applying  to 
cancer  in  general,  however  they  may  apply  to  a  particular 
case.  It  is  not  claimed  that  any  of  the  data  cited  above  are 
specific  for  cancer,  for  very  similar  finds  are  seen  in  other 
malignant  growths,  and  even  in  certain  benign  tumors. 

In  regard  to  autolytic  changes  which  indicate  that  some  sort 
of  retrograde  alteration  has  begun,  no  one  knows  just  when 
and  how  this  is  brought  about.  The  tendency  of  many  cancers, 
like  those  of  the  cervix,  is  to  very  early  softening — the  latter  in 
fact  is  one  of  the  earliest  diagnostic  symptoms,  although  this 
is  found  only  in  certain  kinds  of  epithelioma  which  tend  to 
early  ulceration.  Ordinarily  softening  occurs  much  later  and 
as  a  result  of  several  factors — compression  of  central  cells, 
interference  with  nutrition  through  poor  supply  of  blood,  etc. 
Presumably  autolysis  does  not  begin  until  after  necrosis  has 
occurred,  and  the  latter  may  be  molecular  or  occur  in  mass, 
with  resulting  atrophy  of  cancer  cells  or  the  formation  of 
ulceration,  or  areas  of  degeneration. 

The  inorganic  material  of  cancer  cells  is  of  small  interest 
in  comparison  to  the  large  amount  of  literature  and  the  many 
generalizations  which  have  been  made  on  the  subject.  Young 
cancer  cells  are  poor  in  calcium  and  the  latter  tends  to  increase 
until  in  old  cancers  calcification  may  result.  They  contain 
at  the  outset  much  more  potash  than  lime — in  the  proportion 
of  2  :  i  or  3  :  2.     Later  the  potassium  tends  to  diminish  and 


BIO-CHEMISTRY   OF   CANCER  79 

the  old  cancer  is  very  poor  in  it.  Sodium  is  present  in  larger 
amount  than  potassium  and  apparently  persists  to  the  last 
with  little  or  no  change.  Phosphorus  is  present  in  proportion 
to  the  amount  of  nuclein  in  the  tumor.  Certain  minerals 
which  are  not  constituents  of  the  body  as  selenium  and  uranium 
salts  have  a  selective  attraction  for  cancer  tissue.  The  mag- 
nesium content  of  cancer  is  naturally  feeble,  but  we  find  no 
accurate  figures  for  sulphur  or  other  mineral  content. 

An  extraordinary  number  of  active  substances  have  been 
described  as  cancer  products.  These  have  been  studied 
through  the  behavior  of  cancer  extracts  for  the  most  part. 
The  amino-acids  of  katabolism  are  not  included  here  although 
some  of  them  show  activity,  in  being  able  to  inhibit  cancer  cell 
growth  in  experiment.  Fresh  cancer  extract  contains  a  variety 
of  enzymes  such  as  are  found  in  ordinary  tissue  cells,  and  some 
show  marked  proteolytic  powers  with  normal  tissues,  which 
suggests  the  old  belief  that  cancer  digested  its  way  to  some 
extent  through  sound  tissues.  Loeper  claims  that  the  proteo- 
lytic enzyme  enters  the  blood  and  can  lower  the  azotemic 
coefficient  of  the  same.  Cancer-juice  can  digest  more  peptone 
or  rather  produce  more  amino-acid  than  other  and  normal 
tissues.  The  products  of  autolytic  enzymes  have  been  summed 
up  as  autolysates,  and  some  of  these  are  doubtless  toxic,  as 
shown  by  their  ability  to  cause  hemolysis.  The  enzyme  of 
growing  cancer  cells  has  been  pronounced  to  be  erepsine. 
Lumiere  has  announced  that  young  cancer  cell  extract  is  toxic 
to  small  animals,  although  many  experiments  along  this  line 
have  given  negative  results.  Cancer  extracts  have  proved 
toxic  to  protozoa.  It  must  be  said  emphatically  of  autolytic 
cancer  extracts  that  they  are  not  in  the  least  specific,  and  that 
they  are  identical  with  those  produced  when  a  large  benign 
tumor  like  a  fibroma  undergoes  necrosis.  Such  extracts  also  pro- 
duce hemolysis.     Possible  lysin  formation  has  been  mentioned. 

The  supposed  desmoplastic  substance  has  already  been  men- 
tioned. It  is  formed  clearly  from  the  young,  growing,  tumor 
cell  and  of  its  nature  nothing  is  known. 


8o  CANCER 

Finally,  for  the  sake  of  completeness,  we  may  mention  that 
cancer  of  glandular  and  endocrinic  organs  can  produce  the 
special  secretions  and  hormones  of  these  organs,  so  that  cancer 
may  actually  be  seen  in  the  role  of  a  physiological  organ.  The 
mucous  gland  cancer  may  produce  mucus  ("colloid"  matter  is 
really  of  this  nature),  the  liver  cancer  cell  has  not  become  ana- 
plastic and  still  secretes  bile,  the  cancer  cell  of  the  thyroid 
produces  thyroidin  and  the  adrenal  cell  adrenalin.  In  addi- 
tion to  the  normal  functions  these  cancerous  secretions  can  set 
up  diseases  such  as  follow  excess  of  internal  secretion.  But  phe- 
nomena of  this  kind  are  very  rare  and  merely  curiosities  of  medi- 
cine. That  ordinary  cancer  cells  produce  bodies  worthy  to  be 
called  hormones  has  not  been  definitely  proven,  though  widely 
accepted,  but  it  is  possible  that  the  decidual  cell  which  produces 
chorioepithelioma  may  secrete  a  substance  of  this  kind,  as  shown 
by  the  changes  in  the  corpora  lutea  in  that  affection;  on  the  other 
hand,  the  claim  is  equally  made  that  irregularities  in  the  secre- 
tion of  lutein  are  responsible  for  the  genesis  of  these  tumors. 

While  no  specific  or  definite  information  leading  to  a  knowl- 
edge of  the  true  nature  of  cancer  is  afforded  by  these  or  other 
accessible  researches,  there  runs  through  many  of  them  a  thread 
of  thought  which  is  important. 

It  will  be  noticed  how  many  of  these  studies  relate  to  the  dis- 
integration of  protein,  to  protolytic  ferments,  to  nuclein,  to 
lymphocytosis,  to  autolytic  action,  etc.,  all  of  which  go  to  con- 
firm the  thesis  on  which  our  study  is  based.  Namely  that 
errors  in  the  blood  content  are  the  true  cause  of  cancer,  and  it 
will  be  worth  while  to  consider  some  of  these  matters  more  fully. 

We  have  always  held  that  errors  in  regard  to  protein  cleavage 
is  at  the  root  of  cancer,  and  that  while  this  substance  is  neces- 
sary in  building  up  the  individual  elements  composing  the  sys- 
tem, an  excess  of  animal  protein  decomposes  wrongly,  while  that 
from  the  vegetable  kingdom  assimilates  perfectly,  and  can 
supply  all  the  wants  of  the  system.  This  is  seen  in  animals, 
where  those  who  live  from  the  ground  are  free  from  cancer,  also 


BIO-CHEMISTRY   OF   CANCER  81 

native  aborigines,  who  subsist  mainly  on  vegetable  products, 
escape,  but  the  latter  readily  acquire  cancer  when  living  with 
Europeans  and  partaking  largely  of  animal  food. 

Few  realize  what  nuclein  is  and  the  enormous  part  which  it 
plays  in  the  organism.  Some  one  has  said  that  "nuclein  is  life, " 
for  it  forms  part  of  every  cell  in  the  animal  or  vegetable  king- 
dom. It  exists  in  every  cell  in  the  body  and  is  the  controlling 
element  in  the  nucleus  of  each  cell,  and  exists  in  the  primordial 
cell  from  which  every  organism  is  formed.  It  would  carry  us 
too  far  to  attempt  to  discuss  the  cell  changes  involved  in  ami- 
tosis  and  mitosis,  and  the  operation  of  the  centrosomes  and 
chromosomes  in  effecting  the  reproduction  of  cells  in  normal 
tissues. 

Ewing  says1:  "Tumor  cells  exhibit  a  wide  variety  of  altera- 
tions which  have  been  subjected  to  close  scrutiny,  but  which  it  is 
difficult  to  interpret  and  classify.  These  changes  affect  both  the 
nucleus  and  the  cytoplasm.  In  the  highly  developed  tumor-cell 
the  nucleus  may  be  distinguished  by  five  elements :  i.  Nuclein, 
a  nucleo-protein,  composing  the  chromatin,  which  appears  in 
densely  basic  staining  clumps,  normally  arranged  along  the 
periphery  of  the  nucleus,  or  as  an  intra-nuclear  network.  2. 
Paranuclein,  an  acidophile  substance  composing  the  nucleoli. 
3.  Linin,  or  plastin,  an  achromatic  substance,  forming  an  in- 
tranuclear network.  4.  Amphipyrenin,  which  some  authors 
describe  as  constituting  the  nuclear  membrane.  5.  Nuclear 
fluid;  filling  the  meshes  of  the  nuclear  network. 

"As  compared  with  normal  cells  all  these  nuclear  structures 
may  be  much  more  abundant  in  tumor  cells.  In  giant  cells, 
especially  those  of  myogenous  origin,  and  in  various  sarcomas 
and  epitheliomas,  the  nuclei  reach  astonishing  proportions  from 
hyperhypertrophy,  chiefly  of  nuclein.  In  epitheliomas  great 
excess  and  multiplicity  of  paranuclein  bodies  is  somewhat  char- 
acteristic, while  in  endotheliomas  the  nuclei  are  relatively  small. 

"Shrinkage  and  pyknosis  of  nuclei  occur  in  degenerating  and 
necrosing  areas  of  many  tumors.     Wide  distension,  from  inhibi- 

1  Ewing,  "Neoplastic  Diseases."     Philadelphia,  1919,  p.  46. 
6 


82  CANCER 

tion  of  fluids,  may  accompany  hydropic  degeneration  of  the 
cytoplasm.  Rarefaction  of  nuclein  masses  may  result  in  a  pale, 
diffuse  stain  of  the  thickened  chromatic  network.  Or  the  chro- 
matin may  appear  in  very  thin  strands  eventually  disappearing 
in  complete  karyolysis.  A  common  appearance  in  carcinomas 
is  the  presence  of  several  discrete  blocks  of  chromatin,  lying 
irregularly  in  a  nucleus  devoid  of  chromatic  membrane.  The 
various  stages  of  karyorrhexis  may  be  followed  in  degenerating 
or  necrosing  cells.  The  fragments  of  chromatin  thus  resulting 
may  be  scattered  in  the  cytoplasm  and  remain  pyknotic  or 
become  vacuolated  or  surrounded  by  cytoplasmic  vacuoles,  or 
become  dissolved.  Extrusion  of  chromatin  into  the  cytoplasm 
may  result  in  the  appearance  of  many  basophile  granules  in  the 
cell.  The  chromatin  or  linin  may  break  up  into  many  fine  rings 
within  the  nucleus,  and  then  be  discharged  into  the  cytoplasm." 

It  is  unnecessary  to  follow  this  interesting  study  further,  to 
which  a  number  of  pages  are  devoted,  but  enough  has  been 
given  to  show  how  the  active  properties  of  the  cells  change  and 
become  distorted  when  they  take  on  their  riotous  action. 

Now  what  is  the  cause  of  this  disastrous,  wild,  unnatural 
behaviour  of  living  cells  which  should  be  performing  their 
normal  functions  of  mitosis,  and  reproduction  of  healthy  cells 
to  take  their  place  in  the  tissues?  Why  do  not  these  morbid 
changes  take  place  in  the  earlier  years  of  life?  Why  do  they 
persist  in  their  mad  career,  inducing  many  other  cells  to  join 
in  riotous  action?  Why  does  the  process  go  on  until  a  per- 
nicious anaemia  destroys  life?  These  and  other  matters  will 
be  considered  more  fully  in  later  chapters,  but  the  single  answer 
to  all  of  them  may  be  given  here. 

All  the  cells  of  the  body  depend  for  their  constant  nourish- 
ment on  the  circulating  blood,  and  lymph,  and  I  cannot  do 
better  here  than  to  use  some  of  the  practical  and  sane  thoughts 
given  to  us  by  Dr.  Robert  Bell1  of  London,  who  has  done  so 
much   to   establish   the   constitutional   relation   of   cancer,   in 

1  Bell,  "Cancer,  Its  Cause  and  Treatment  without  Operation.  London, 
1913,  p.  176. 


BIO-CHEMISTRY  OF   CANCER  83 

spite  of  the  opposition  of  those  adhering  to  the  present  surgical 
views. 

Says  Dr.  Bell:  "The  cancer  cell  is  primarily  a  normal  cell 
that  has  rebelled  against  the  persistent  ill  usage  it  has  been 
subjected  to.  In  consequence  of  this  it  has  gradually  parted 
with  its  loyalty  to  those  physiological  laws  which  hitherto  have 
regulated  its  cycle  of  life.  We  know  it  of  old  as  an  active,  pro- 
lific, versatile,  and  adaptable  cell.  It  can  be  successfully  trans- 
planted from  one  individual  to  another,  and  it  is  even  capable  of 
taking  up  a  novel  position,  and  carrying  on  its  existence  within 
a  muscle,  for  example,  when  it  has  been  carried  into  such  a 
structure  through  a  wound. 

"Is  it  to  be  wondered  at  them,  that,  as  we  know  to  our  cost,  a 
cell  may,  and  does  frequently  throw  off  its  allegiance  to  those 
laws  which  govern  healthy  cell  metabolism,  and  take  up  a  new 
role  of  existence  and  adopt  cannibal  proclivities,  which  it  does 
when  it  develops  into  a  cancer  cell.  Now,  if  the  various  cells 
and  organs  of  the  body  are  for  a  lengthened  period  to  derive 
their  nourishment  from  a  vitiated  blood  supply,  no  matter 
what  the  pollution  consists  of,  is  it  reasonable  to  expect  that 
they  will  be  able  to  continue  in  healthy  vigor,  and  be  competent 
to  carry  on  their  various  functions  satisfactorily?  Need  we 
wonder  if  then  physiological  harmony  is  seriously  interfered 
with,  and  that  a  spirit  of  mutiny  should  arise — just  as  in  an 
army,  for  instance,  when  the  food  supply  is  considered  defec- 
tive— and  that  if  matters  are  not  speedily  rectified  this  mutiny 
should  spread  till  eventually  the  whole  fabric  is  overthrown?" 
It  is  quite  possible  to  suppose  that  the  organs  or  cells  which 
create  the  nuclein,  which  other  cells  seize  on  and  use  as  their 
controlling  agent,  do  not  then  afford  a  perfect  nuclein,  and  the 
vicious  circle  is  continued  until  death  ends  the  scene.  Later  on 
the  elements  which  combine  to  make  the  vitiated  blood  stream 
will  be  considered. 

An  interesting  suggestion  as  to  why  cancerous  changes  in 
cells  do  not  ordinarily  occur  in  the  earlier  years  of  life,  is  made 
in  the  remarkable  book  on  the  study  of  "Induced  Cell-repro- 


84  CANCER 

duction  and  Cancer,"  by  Hugh  Campbell  Ross,  with  others,  in 
regard  to  the  reason  for  the  non-early  development  of 
cancer.1 

We  know  that  in  certain  tissues,  cells  are  continually 
dying  and  being  replaced,  so  that  it  is  evident  that  birth 
and  death  must  be  going  on  incessantly  in  the  body. 
What  happens  to  the  dead  cells?  They,  of  course,  liquefy 
and  become  disorganized,  and  their  constituents  are  pre- 
sumably excreted  or  converted  into  other  compounds.  While 
this  is  happening,  it  seems  probable  that  some  of  the  prod- 
ucts of  the  remains  of  the  dead  cells  may  be  absorbed 
by  their  neighbors,  for  it  must  be  remembered  that  the  diffusion 
of  substances  into  living  cells  appears  to  be  a  physical  process 
over  which  they  have  no  control.  Many  cells  live  only  a  very 
short  time,  the  length  of  their  lives  varying  perhaps  in  different 
parts  of  the  body,  so  that  the  remains  of  dead  cells  are  probably 
always  present  in  the  body  fluids.  In  this  connection,  however, 
we  have  to  keep  in  mind  the  physiological  curve  expressing  the 
relationship  between  katabolism  and  anabolism.  There  are 
only  three  stages  of  life,  if  it  is  regarded  from  this  point  of  view, 
the  first  terminating  at  about  the  thirtieth  year,  when  man 
reaches  his  prime,  and  up  to  which  period  cellular  birth  must 
preponderate  over  its  death  rate.  For  some  years  it  may  be 
suggested  that  katabolism  and  anabolism  remain  balanced; 
and  that  after  the  age  of  40,  quite  physiologically,  so  that 
nothing  occurs  to  make  one  aware  of  it  physically,  these  condi- 
tions begin  to  be  reversed,  and  more  of  the  products  of  katabol- 
ism— that  is,  the  remains  of  dead  cells — tend  to  exist  in  the 
body  fluids  than  was  the  case  before  middle  age. 

"Here  we  have  a  fact  incidental  to  the  cancer  period,  which 
suggests  the  possibility  that  these  products  of  katabolism  may 
in  some  way  predispose  to  the  onset  of  malignancy.  Thus, 
some  certain  morphological  (chemical)  element  in  a  dead  cell 
may  be  the  agent.     For  the  sake  of  argument  it  may  be  derived 

1  Ross.,  "Induced  Cell-production  and  Cancer."  Philadelphia,  191 1,  p.  361. 
Also  "Further  Researches."     Vol.  I,  II. 


BIO-CHEMISTRY   OF   CANCER  85 

from  either  the  cytoplasm,  the  cell  wall,  the  nuclear  wall,  or  the 
lining,  or  it  may  be  the  chromatin  itself." 

The  age  factor  has  always  been  one  of  the  problems  of  cancer, 
and  few  have  attempted  to  explain  it,  other  than  that  it  belongs 
to  the  declining  years,  when  active  constructive  metabolism  has 
ceased,  and  degenerative  changes  are  prone  to  occur.  This 
may,  therefore,  be  a  rational  explanation  of  the  actual  process 
by  means  of  which  certain  cells  in  different  parts  of  the  body 
take  on  that  virulent  action  to  which  we  give  the  name  of  cancer, 
when  the  other  contributing  agents,  to  be  considered  later, 
exist  in  the  economy. 


CHAPTER  VI 
DIAGNOSIS  OF  CANCER 

Various  societies  for  the  prevention  of  cancer  have  of  late 
years  made  strenuous  endeavors  to  educate  the  medical  profes- 
sion and  laity  in  regard  to  its  early  recognition,  with  a  view  to 
reaching  the  disease  by  the  prompt  surgical  removal  of  the 
discovered  local  lesion.  If  the  early  recognition  of  cancer  is 
important  from  a  surgical  point  of  view,  it  is  manifestly  of  even 
greater  importance  from  a  medical  aspect,  inasmuch  as  prophy- 
laxis is  always  more  desirable  than  cure.  Too  much  attention 
and  thought  therefore  can  hardly  be  paid  both  to  the  early 
detection  of  the  first  signs  of  a  cancerous  growth  and  to  the 
recognition  of  the  constitutional  conditions  which  lead  up  to 
the  disease,  as  will  be  developed  in  subsequent  chapters.  For 
experience  has  shown  that  if  these  systemic  conditions  can 
be  fully  met  and  overcome  by  proper  measures,  the  process 
inducing  the  wrong  cell  action  which  resulted  in  the  malignant 
disease,  will  be  reversed,  and  absorption  of  the  wrongly  formed 
cells  will  result. 

When  the  disease  has  lasted  some  time,  and  there  is  a  larger 
mass  of  disordered  cells,  it  is  naturally  less  easy  to  effect  such 
an  absorption,  and  when  by  longer  continuance  there  is  glandu- 
lar involvement  or  metastasis  to  other  parts,  it  is,  of  course, 
more  difficult  for  the  revitalized  blood  stream  to  affect  them 
all.  Moreover,  as  the  disease  progresses  all  these  foci  of  degen- 
erated cells  must  give  forth  products  of  their  catabolistic  and 
anabolistic  changes  (which  cannot  be  the  same  as  the  hormone 
resulting  from  the  disintegration  of  normal,  healthy  cells)  poison- 
ing the  system  and  disintegrating  the  blood,  and  the  task  of 
regenerating  the  blood  stream,  from  which  all  cells  derive  their 
sustenance,  becomes  still  harder.  But,  as  will  appear  from  the 
cases  recorded  later,  even  in  advanced  cancer  and  in  recurrences 

86 


DIAGNOSIS  OF  CANCER  87 

after  surgical  removal  it  is  possible  to  effect  changes  which  are 
often  most  remarkable. 

It  is  readily  seen,  therefore,  how  essential  it  is  in  any  attempt 
at  a  medical  treatment  of  cancer  to  begin  at  the  earliest  possible 
moment  the  work  of  changing  the  constitutional  conditions 
of  the  system  upon  which  the  malignant  process  depends. 
It  is  seen  also  how  erroneous  it  is  to  simply  watch  and  observe 
a  patient,  as  is  often  done,  to  see  if  the  lesion  suspected  to  be  a 
beginning  cancer  will  develop  further;  for  of  course,  the  longer 
the  systemic  disorder  continues  the  more  foci  of  disease  will 
develop,  and  the  harder  it  will  be  to  reverse  the  faulty  meta- 
bolism and  to  induce  a  healthy  action  in  the  diseased  tissues. 

Even  the  smallest  mass  which  can  be  found  in  a  woman's 
breast  has  not  been  formed  in  a  day,  or  a  week,  or  a  month,  but 
the  thousands  of  deranged  cells  of  which  it  is  composed  have 
been  accumulating  perhaps  for  months,  and  the  disordered 
blood  condition  producing  them  naturally  dates  back  much 
longer. 

Furthermore,  if  by  chance  an  operation  has  been  performed 
to  remove  one  or  more  of  the  diseased  portions,  how  unreason- 
able it  is  to  leave  the  patient  with  the  same  proclivities  to 
cancer,  which  so  constantly  re-develop  either  in  or  near  the 
original  site,  or  in  other  locations,  when  this  tendency  to 
recurrence  can  be  checked  by  proper  medical  attention. 

Over  one  hundred  years  ago  the  great  English  surgeon 
Abernethy1  wrote  very  pointedly  in  regard  to  this.  Says  he: 
"There  can  be  no  subject  which  I  think  more  likely  to  interest 
the  mind  of  the  surgeon  than  that  of  an  endeavor  to  amend 
and  alter  that  state  of  a  cancerous  constitution.  The  best 
timed  and  best  conducted  operation  brings  with  it  nothing  but 
disgrace,  if  the  diseased  propensities  of  the  constitution  are 
active  and  powerful.  It  is  after  an  operation  that,  in  my 
opinion,  we  are  most  particularly  incited  to  regulate  the  consti- 
tution, lest  the  disease  should  be  revived  or  renewed  by  its 
disturbance."  In  later  chapters  we  shall  see  what  these 
1  Abernethy,  "Surgical  Observations  on  Tumors."    London,  1816,  p.  221. 


88  CANCER 

disturbances  are  and  what  measures  should  be  adopted  to  alter 
them. 

It  will  be  impossible  in  the  present  compass  to  go  as  fully 
into  the  diagnosis  of  cancer  in  different  localities  as  could  be 
desired,  and  reference  must  be  made  to  some  of  the  many 
surgical  works  on  the  disease,  where  these  are  elaborated.  For 
unfortunately,  although,  as  will  be  seen,  while  cancer  is  rightly 
a  medical  and  not  a  surgical  affection,  medical  men  have  not 
heretofore  interested  themselves  in  it  to  any  great  degree, 
but  have  left  its  description  as  well  as  treatment  to  the  surgeons. 
But  a  brief  presentation  of  some  of  the  salient  points  will  help 
in  grasping  the  subject  under  discussion. 

In  the  preceding  chapter  we  have  seen  that  the  actual  begin- 
ning of  the  histological  cell  disturbance  which  eventuates  in 
the  tumor  which  we  call  cancer,  is  somewhat  uncertain,  and 
undoubtedly  the  disease  has  been  going  on  in  individual  cells 
long,  long  before  their  accumulation  has  formed  a  mass  large 
enough  to  suffice  for  detection.  Thus  too  often  there  is  already 
such  a  general  carcinosis  habit  of  body  developed  that  surgeons 
agree  that  at  least  50  per  cent  of  true  cancer  cases  (excluding 
cutaneous  epithelioma)  come  to  them  when  too  late  for  success- 
ful operation:  moreover  the  proportion  of  cases  which  remain 
ultimately  well  for  a  long  period  of  years  is  exceedingly  small. 
Hence,  the  very  great  importance  of  recognizing  at  the  earliest 
possible  moment  both  the  local  manifestation  of  the  disease 
and  especially  the  constitutional  elements  leading  up  to  cancer, 
as  described  in  other  chapters. 

In  regard  to  the  actual  appearances,  or  recognizable  local 
symptoms  which  may  be  discovered  by  sight  and  touch,  we 
may  briefly  take  up  the  disease  as  it  affects  various  organs  or 
portions  of  the  body.  We  will  begin  with  epithelioma  of  the 
skin,  which,  however,  being  such  a  peculiarly  local  affection, 
often  readily  amenable  to  correct  local  treatment,  especially  if 
taken  early,  is  not  considered  in  this  book  as  true  cancer,  and 
is  but  little  influenced  by  internal  medical  measures. 


DIAGNOSIS  OF  CANCER  89 

Epithelioma  of  the  Skin. — Synonyms:  Epithelial  cancer; 
Epidermoid  carcinoma;  Cancroide;  Rodent  ulcer.  The  forms 
and  appearances  of  epithelioma,  both  baso-cellular  and  spino- 
cellular,  in  different  degrees  and  stages  vary  so  greatly  that 
those  unacquainted  with  the  disease  may  fail  to  appreciate  the 
lesion:  cases  also  differ  greatly  in  their  malignity.  The  begin- 
ning is  always  very  small,  and  commonly  its  real  nature  is  not 
recognized  until  it  has  lasted  some  time.  The  disease  may 
start  from  a  mole  or  wart,  or  from  a  hardened  sebaceous  con- 
gretion,  or  it  begins  unrecognized  as  a  scaly  patch,  which 
exhibits  a  raw  and  frequently  slightly  bleeding  surface,  when- 
ever the  crust  is  picked  or  rubbed  off.  Soon  greater  infiltra- 
tion is  manifested  and  more  ulceration:  in  the  progress  of  the 
disease,  small  pearly,  rather  translucent  tubercles,  hard  and 
cartilaginous,  are  commonly  formed,  often  as  a  ring  around 
the  margin.  When  irritated  by  injudicious  treatment  the 
edge  becomes  hard,  infiltrated,  and  elevated,  the  ulcer  extends 
and  deepens,  and  great  destruction  of  tissues,  even  of  the  bones, 
may  result  (Rodent  ulcer,  Jacobs'  ulcer,  Noli  me  tangere). 
In  occasional  instances  the  disease  may  remain  quiescent  for 
years,  slowly  increasing  so  as  to  cover  a  large  area. 

Epithelioma  is  a  disease  of  middle  or  advanced  age,  and  is 
relatively  infrequent,  forming  about  2  per  cent  of  30,000  mis- 
cellaneous skin  cases  analyzed.  In  the  beginning  it  may  be 
confounded  with  eczema  or  horny  seborrhcea,  and  in  later 
stages  with  lupus  or  the  later  manifestations  of  syphilis.  Many 
syphilitic  lesions,  even  the  chancre,  when  occurring  on  the  skin, 
have  occasionally  been  excised  as  epithelioma. 

Epithelioma  of  the  mucous  membranes  is  quite  a  different 
affair,  and  is  rightly  called  by  Ewing  epidermoid  carcinoma,  for 
it  is  characterized  almost  invariably  by  metastases  in  the  lym- 
phatics and  other  tissues. 

Epidermoid  Carcinoma  of  the  Lip  and  Buccal  Cavity. — On  the 
lip  the  disease  begins  very  insidiously,  in  a  crack  or  fissure,  and 
most  commonly  in  smokers,  and  as  the  sore  refuses  to  heal,  more 
or  less  of  an  almost  cartilaginous  hardness  forms,  and  with  it  a 


qo  CANCER 

greater  or  less  involvement  of  sub-maxillary  glands.  When  not 
too  greatly  irritated  it  may  progress  slowly,  and  not  ulcerate 
much,  but  the  tendency  is  to  increase  in  size,  ultimately  pro- 
ducing great  destruction  and  tending  to  destroy  life,  if  the 
progress  is  not  checked  by  a  relatively  early  and  complete  treat- 
ment. Unfortunately  involvement  of  the  glands  too  often 
follows  surgical  removal  and  the  patient  succumbs. 

Cancer  of  the  Tongue. — This  is  generally  a  most  serious  affair, 
of  which  the  diagnosis  is  often  very  difficult  in  its  earlier  stages; 
quite  innocent  abrasions  or  ulcerations  of  the  tongue  may  pass 
into  cancer,  and  leucoplakia  is  found  to  be  a  frequent  pre-can- 
cerous  condition.  The  very  early  diagnosis  of  cancer  of  the 
tongue  is  often  most  difficult,  and  yet  most  important,  both  from 
a  medical  and  a  surgical  aspect,  for,  as  Butlin1  remarks:  "There 
is  ample  evidence  to  prove  that  many  forms  of  the  disease  in 
which  cancer  appears,  are  in  the  first  instance,  and  even  for  a 
time  after  their  first  appearance,  simple,  non-cancerous  affec- 
tions. But  the  great  interest  in  relation  to  them  is  to  study 
carefully  the  manner  in  which  each  of  them  becomes  carcino- 
matous, and  above  all  to  strive  to  arrive  by  the  most  careful 
study,  at  the  signs  by  which  the  actual  development  of  carci- 
noma in  each  of  them  may  be  perceived." 

The  sore  place,  no  matter  what  its  origin,  whether  from  an 
apthous  sore,  or  a  jagged  tooth,  or  a  leucoplakia,  or  a  syphilitic 
lesion,  is  at  first,  not  at  all  suggestive  of  malignant  disease,  and  it 
is  extremely  difficult  to  be  certain  just  when  it  has  become  car- 
cinomatous, and  it  is  precisely  in  this  stage  that  exactly  right 
medical  treatment  is  most  effective  as  will  be  mentioned  later: 
but  if  irritated  by  ill  advised  treatment,  as  by  nitrate  of  silver, 
it  slowly  enlarges,  the  base  ulcerates  and  the  edges  harden,  more 
or  less  adenopathy  develops,  and  it  has  entered  the  carcinoma- 
tous stage.  The  later  progress  is  generally  much  more  rapid, 
and  if  untreated  it  can  end  life  in  eighteen  months,  and  the  end 
results  of  surgical  operation  are  most  unsatisfactory,  glandular 
recurrence  being  almost  universal. 

1  Butlin,  Henry  T.,  "Diseases  of  the  Tongue."     Philadelphia,  1885,  p.  270. 


DIAGNOSIS  OF  CANCER  91 

The  later  developments  of  cancer  lesions  on  the  tongue  are 
very  varied,  but  as  a  rule  almost  unmistakable,  and  can  hardly 
be  briefly  described.  There  is  a  raw,  granulating  surface,  with 
rolled  edges,  upon  a  greatly  hardened  base,  and  giving  off 
considerable  fetid  pus.  Later  in  the  disease  the  malignant 
process  has  often  spread  to  adjoining  parts,  the  tongue  is  more 
or  less  immovable,  rendering  mastication  and  deglutition  almost 
impossible,  and  the  pain  may  be  very  great;  death  results  from 
inanition  rather  than  from  the  cancerous  cachexia  found  with 
cancer  elsewhere. 

The  mouth  lesions  are  to  be  differentiated  from :  1.  Aphthous 
stomatitis;  2.  Simple  ulceration  of  the  tongue;  3.  Syphilitic 
lesions,  including  chancre;  4.  Leukoplakia,  and  5.  Tubercular 
lesions. 

Carcinoma  of  the  Cheek. — The  disease  is  also  difficult  of  defi- 
nite recognition  in  its  very  early  stages  in  this  locality  as  well  as 
on  the  tongue,  and  the  diagnosis  is  much  the  same  as  in  that 
location.  The  lesion  is  very  apt  to  develop  upon  patches  of 
leucoplakia,  and  is  very  often  found  opposite  the  back  teeth, 
and  may  be  from  roughened  tooth  surfaces  and  possibly  from 
amalgum  fillings.  Some  pain  in  eating  generally  first  calls 
attention  to  the  relatively  innocent  lesion.  Presently  more  or 
less  hardness  occurs  over  a  definite,  limited  area,  moderate 
ulceration  then  appears,  with  some  sub-maxillary  glandular 
enlargement.  As  the  disease  increases  the  ulceration  increases, 
the  jaws  stiffen  and  proper  mastication  is  difficult,  and  when 
fully  established  the  progress  is  more  rapid.  The  disease,  how- 
ever, is  apt  to  be  rather  sluggish  and  does  not  affect  the  glands 
as  much  as  tongue  cancer. 

Carcinoma  of  the  Palate  presents  an  eroded  surface,  with 
hard  edges,  which  may  extend  over  the  tonsils  and  uvula.  It 
is  relatively  rare,  and  is  seldom  diagnosed  until  too  late  for  any 
surgical  operation,  which  later  is  most  unsatisfactory,  owing 
largely  to  the  involvement  of  deep  lymphatics.  It  should  be 
carefully  diagnosticated  from  syphilitic  lesions. 


92  CANCER 

Cancer  of  the  (Esophagus. — The  early  diagnosis  of  cancer  in 
this  location- is  difficult  indeed.  The  first  symptom  is  generally 
dysphagia,  in  swallowing  hard  pieces  of  food,  the  attacks  being 
temporary,  increasing  in  severity,  until  even  liquid  foods  are 
resisted  and  regurgitation  occurs:  the  material  brought  up  is 
distinguished  from  stomach  contents  by  its  alkalinity  and  by 
the  absence  of  gastric  juice  and  the  products  of  digestion.  As 
the  disease  advances  there  is  distinct  pain,  sometimes  of  very 
severe  character,  especially  after  taking  food.  Coughing  is 
often  a  symptom,  and  occasionally  loss  of  voice  and  dyspnoea, 
from  paralysis  of  the  recurrent  laryngeal  nerves.  Emaciation 
occurs  from  inability  to  take  proper  nourishment. 

Accurate  diagnosis  may  be  finally  established  by  the  #-ray, 
showing  the  tumor  and  often  dilatations  of  the  oesophagus 
above  it.  A  direct  view  of  the  growth  may  be  obtained  by  the 
cesophagoscope,  and  bougies,  if  carefully  used,  will  detect 
obstructions  produced  by  the  tumor. 

Cancer  of  the  Stomach  presents  very  great  difficulty  of  early 
diagnosis  as  such,  so  that  thus  far  it  is  agreed  that  about  50 
per  cent  of  the  cases  are  fully  diagnosed  only  when  it  is  already 
too  late  to  expect  any  permanent  beneficial  results  from  surgery ; 
how  very  important  it  is,  therefore,  to  recognize  and  thoroughly 
treat  the  antecedents  of  this  insidious  affection.  The  early 
symptoms  are  commonly  pain  or  discomfort  in  the  epigastric 
region,  loss  of  appetite,  vomiting,  loss  of  weight,  and  general 
weakness.  But  some  cases  give  practically  no  symptoms  until 
the  disease  is  far  advanced.  In  other  instances  there  is  a  long 
history  of  obstinate  dyspepsia,  in  others,  a  sudden  attack  from 
indiscretion  in  diet  will  first  disclose  that  there  is  an  ulcer 
preceding  cancer,  or  an  already  developed  neoplasm.  The 
constant  absence  or  great  reduction  of  hydrochloric  acid  and 
the  presence  of  lactic  acid  are  strongly  indicative  of  cancer,  as 
also  the  well  known  Boas'  tests,  and  the  discovery  of  the  Boas- 
Oppler  bacillus. 

The  s-ray  is  often  of  service  when  a  cancerous  mass  has 
formed,  and  careful  auscultatory  percussion  will  often  discover 


DIAGNOSIS  OF  CANCER  93 

the  lesion,  but  may  not  until  the  tumor  is  of  some  size.  When 
pain  is  experienced  in  this  prodedure  the  diagnosis  is  more 
probable.  In  its  late  and  fatal  stages,  however,  from  which 
mortality  figures  are  taken,  the  diagnosis  is  relatively  easy; 
in  all  recent  statistics  the  mortality  of  cancer  of  the  stomach 
and  liver  forms  about  40  per  cent  of  the  total  deaths  from 
cancer,  and  these  are  increasing  in  men  more  than  in  women. 
It  is  a  disease  of  adult  life,  about  90  per  cent  of  all  patients 
being  between  the  ages  of  40  and  70,  and  only  about  2  per 
cent  before  the  age  of  30  years. 

Cancer  of  the  Intestine. — Here  the  early  diagnosis  is  even  more 
perplexing,  and  is  rarely  established  early,  or  until  the  diseased 
mass  has  greatly  advanced,  and  even  a  stricture  has  formed. 
Indefinite  and  more  or  less  colicky  pain,  not  necessarily  associ- 
ated with  digestion,  together  with  flatulence,  causing  abdominal 
distension,  are  usually  premonitory  signs.  There  is  almost 
always  irregular  action  of  the  bowels,  generally  constipation, 
alternated  with  diarrhoea.  When  there  is  obstruction  caused 
by  the  tumor  formed,  the  action  of  the  intestines  maybe  spasmo- 
dic and  intussusception  may  occur,  with  great  pain. 

Naturally  the  recognition  of  a  tumor  in  the  intestine  is  very 
difficult  until  it  has  attained  some  size,  and  even  very  careful 
palpation  and  percussion  may  fail  to  distinguish  between  it  and 
fecal  retention,  which  latter,  however,  may  aid  diagnosis,  as 
indicating  an  obstruction.  The  x-ray,  if  rightly  interpreted, 
can  help  in  a  measure.  The  character  of  the  feces  may  be  an 
aid,  when  carefully  examined  microscopically.  Blood,  occult  or 
visible  in  the  stools,  should  always  be  suggestive  of  cancer, 
either  of  the  stomach  or  intestinal  tract,  and,  of  course,  if 
pieces  or  particles  of  neoplastic  growth  are  found  the  diagnosis 
is  assured.  While  piles  are  not  commonly  associated  with 
cancer  of  the  rectum,  any  hardening  of  them  or  ulceration 
should  always  be  suggestive  and  indicate  closer  examination. 

Cancer  of  the  Pancreas. — Pain  in  the  epigastric  region,  often 
radiating  to  the  back,  is  one  of  the  earliest  signs  of  cancer  of  the 
pancreas,  and  is  very  constant.     Jaundice  occurs  early  and  the 


94  CANCER 

liver  and  gall  bladder  are  greatly  enlarged,  with  ascites,  as 
carcinoma,  commonly  at  the  head  of  the  pancreas,  obstructs  the 
common  bile  duct.  Later  in  the  disease  there  is  apt  to  be 
glycosuria  and  stools  containing  free  fat  and  undigested  meat 
particles.  By  this  time  the  tumor  can  be  palpated  in  a  good 
proportion  of  cases.  Cachexia  usually  sets  in  pretty  early  and 
is  rapid  in  progress,  and  metastases,  which  are  abundant,  aid  in 
destroying  life. 

Cancer  of  the  Liver. — The  early  diagnosis  of  primary  cancer  of 
the  liver,  which  is  very  rare,  is  well  nigh  impossible,  and  later 
the  symptoms  depend  on  the  extent  of  the  disease  and  the 
general  weakness,  etc.  Jaundice  is  present  fairly  early  and  is 
continuous,  and  commonly  ascites  at  some  stage  of  the  disease. 

When  the  liver  is  much  affected  secondarily  the  margin  can 
generally  be  easily  felt,  even  below  the  line  of  the  ribs,  and  is 
often  hard  and  knotty. 

Carcinoma  of  the  Gall  Bladder. — This  is  more  easily  deter- 
mined, as  there  is  usually  a  previous  history  of  gall  stones,  but 
in  many  cases  the  malignant  disease  has  not  been  recognized 
until  after  an  operation  for  the  latter. 

Pain  and  tenderness  over  the  gall  bladder  occur  in  over  half 
the  cases,  and  the  tumor  can  be  discovered,  sooner  or  later, 
in  most  instances,  generally  when  it  is  too  late  for  a  successful 
operation.  Jaundice  is  common,  and  ascites  in  25  per  cent  of 
cases.  Vomiting  and  diarrhoea  are  not  uncommon  during  some 
stage,  in  most  instances.  Jaundice  is  generally  present,  often 
due  to  the  presence  of  gall  stones,  before  the  development  of  the 
carcinoma:  ascites  occurs  late,  due  to  secondary  metastases  in 
the    abdomen. 

Carcinoma  of  the  Kidney. — Hematuria,  even  as  very  small 
clots,  is  very  commonly  the  first  sign  of  this  disease,  and  may 
vary  very  greatly  as  to  frequency,  amount,  and  character 
during  the  period  of  the  disease;  it  does  not  occur  especially 
after  exercise,  as  in  renal  calculus,  but  may  appear  in  the  morn- 
ing urine.  Pain  is  not  generally  an  early  symptom,  but  later  is 
of  a  dragging  character  in  the  lumbar  region,  running  down  the 


DIAGNOSIS  OF  CANCER  95 

thigh,  and  may  be  very  severe.  Cachexia  is  not  a  marked 
symptom  until  late  in  the  disease,  and  is  then  rather  due  to 
metastases;  these,  however,  are  not  commonly  recognized, 
except  it  is  stated  the  bones  are  not  infrequently  affected,  and 
renal  carcinoma  should  be  suspected  in  a  patient  with  hematuria 
and  cachexia  when  bone  disease  is  found  in  the  extremities. 

Naturally  the  existence  of  a  tumor  of  the  kidney  cannot  be 
felt  until  the  disease  has  well  progressed,  but  the  #-ray  may  help 
in  a  diagnosis  before  that  time.  Cystoscopy,  showing  a  bleed- 
ing from  one  ureter  aids  also,  if  renal  calculus  can  be  excluded. 

Carcinoma  of  the  Urinary  Bladder. — Here,  also,  hematuria 
is  commonly  the  first  symptom  in  a  large  share  of  the  cases. 
There  may  be  only  a  few  small  clots,  and  not  constant,  or  a 
considerable  amount  of  blood,  well  mixed  with  the  urine.  It 
appears  without  cause,  and  not  especially  connected  with 
exercise,  and  is  often  seen  in  the  morning  urine.  Frequent 
urination  is  a  common  accompaniment,  even  in  early  stages. 
Pain,  or  an  uncomfortable  sensation,  frequently  is  early  and 
continuous.  Competent  cystoscopic  examination  will  com- 
monly establish  the  diagnosis,  even  in  early  cases. 

Carcinoma  of  the  Prostate. — The  early  diagnosis  of  cancer  in 
this  locality  is  very  difficult  if  not  impossible,  so  closely  related 
is  it  to  hypertrophy  of  this  organ  that  it  is  difficult  to  determine 
with  certainty  when  a  malignant  process  has  started.  There  is 
naturally  an  increase  in  the  symptoms  belonging  to  the  benign 
enlargement,  but  with  the  addition  of  pain,  which  may  be  the 
first  symptom,  increasing  as  the  disease  progresses.  It  may  be 
referred  to  the  penis,  testes,  bladder,  thighs,  etc.  Digital 
examination,  from  the  rectum,  may  detect  malignancy  by  the 
stony  hardness,  which  may  affect  a  part  or  the  whole  of  the 
gland.  It  is  stated  that  about  70  per  cent  of  prostatic  carci- 
nomas cause  bone  disease,  so  that  the  discovery  of  such  in  one 
with  much  trouble  in  the  prostate  might  be  a  diagnostic  help. 

Carcinoma  of  the  Uterus. — This  is  a  most  important  subject 
which  merits  the  closest  attention.  For,  as  it  is  recognized  that 
fully  one-half  of  the  cases  which  apply  for  surgical  relief  are 


96  CANCER 

inoperable  when  first  seen  by  the  surgeon,  so  for  the  medical 
treatment  the  chances  are  very  much  better  the  earlier  the 
disease  can  be  recognized.  But,  as  will  be  shown  in  the  final 
chapter,  cancer  can  be  thus  cured  even  when  surgically  inoper- 
able, and  when  this  fact  is  widely  known  physicians  and  patients 
will  look  for  the  earlier  symptoms  and  recognize  the  disease 
sooner,  when  the  terror  of  the  knife  is  replaced  by  the  hope  of 
other  relief.  Space  does  not  admit  of  the  elaboration  of  details 
in  diagnosis  to  the  fullest  extent  desirable,  and  reference  may 
well  be  made  to  the  many  excellent  descriptions  which  have  been 
put  forth  as  arguments  for  surgical  procedures.  The  conditions 
are  so  different  in  cancer  of  the  cervix  and  that  of  the  body  of 
the  uterus,  that  they  will  be  considered  separately. 

Carcinoma  of  the  Cervix. — It  is  doubtful  if  any  one  has  ever 
seen  and  recognized  the  absolutely  first  beginning  of  cervical 
uterine  cancer,  it  is  so  insidious.  As  in  epithelioma  in  other 
locations,  the  earliest  condition  observed  is  a  superficial  erosion 
or  possibly  an  indefinite  papular  elevation,  either  of  which  may 
be  perfectly  benign  and  disappear  under  mild  measures.  For 
it  is  stated  that  two-thirds  of  the  cancers  of  the  cervix  are  epithe- 
liomas, and  only  one-third  adeno-carcinoma  of  this  canal. 
Practically  there  are  no  subjective  symptoms  during  the  very 
early  stage,  but  all  authorities  agree  that  the  first  indications 
that  attract  a  patient's  attention  are:  i.  Irregular  bleeding,  and 
2.  Abnormal  discharge  from  the  vagina;  but  it  is  recognized 
that  when  these  occur  the  malignant  disease  is  already  esta- 
blished. This  bleeding  may  be  very  slight,  and  when  this  occurs 
apart  from  menstruation,  attention  should  always  be  paid  to  it, 
and  a  competent  examination  and  treatment  be  given.  Later 
in  the  disease  this  is  a  conspicuous  feature.  The  vaginal  dis- 
charge, which  later  is  such  a  characteristic  symptom,  is,  of 
course,  very  slight  at  first,  until  some  ulceration  has  taken  place, 
but  at  any  rate  if  there  is  an  appreciable  change  in  a  leucorrheal 
discharge,  discolored  with  blood,  and  peculiarly  offensive,  it  is 
significant,  more  or  less,  of  beginning  trouble,  and  should  be 
attended  to.     There  is  usually  no  pain  in  the  early  stage,  and 


DIAGNOSIS  OF  CANCER  97 

the  patient  often  seems  in  such  perfect  health  that  it  is  difficult 
to  convince  one  that  a  serious  danger  threatens. 

As  the  disease  progresses  there  occurs  more  and  more  ulcera- 
tion, with  exuberant  granulations,  to  which  the  name  of  cauli- 
flower excrescence  has  been  given.  Later  this  increases,  often 
to  a  great  degree,  and  the  adjoining  vaginal  tissue  is  involved. 
By  this  time  there  has  developed  a  hardness  to  the  touch,  so 
different  from  the  normal  condition  of  the  cervix  that  it  is 
almost  pathognomic.  Still  later  the  uterus  is  found  to  be 
more  or  less  fixed,  with  also  an  infiltration  of  the  broad  ligaments. 
There  may  be  urinary  and  rectal  symptoms,  owing  to  the  exten- 
sion of  the  disease,  and  metastases  are  developing  elsewhere. 
As  the  disease  progresses  pain  is  a  marked  feature,  in  the  back, 
thighs,  and  some  in  the  uterus  itself.  By  this  time  the  case  is 
certainly  inoperable,  but,  as  will  be  seen  later,  even  in  very  late 
stages,  the  disease  can  be  overcome  by  exactly  the  proper  in- 
ternal treatment,  dietary  and  other,  with  sufficient  and  correct 
vaginal  douches. 

Carcinoma  of  the  Fundus. — The  diagnosis  of  this  condition  is 
still  more  difficult,  and  commonly  is  not  made  until  the  disease 
is  far  advanced.  Irregular  bleeding  and  altered  vaginal  dis- 
charge are  farily  early  symptoms,  but  these  also  occur  in  con- 
nection with  a  myoma,  or  fibro-myoma,  and  endometritis. 
When  the  discharge  is  fetid  and  mixed  with  blood  it  is  significant. 

Pain  is  not  a  marked  symptom,  even  rather  late  in  the  disease, 
as  the  uterus  is  relatively  insensitive;  although  uterine  colic, 
as  though  expulsion  of  the  diseased  mass  was  attempted,  may 
occur  early,  and  there  may  be  considerable  pain  late,  when 
ulceration  has  occurred,  or  invasion  of  sensitive  adjoining 
structures  has  taken  place.  Cancer  of  the  body  of  the  uterus 
does  not,  as  a  rule,  greatly  enlarge  the  size,  and  external  palpa- 
tion or  vaginal  examination,  digital  or  otherwise,  does  not  es- 
tablish much.  Taylor1  states  that  :  "probably  75  per  cent, 
at  least,  of  the  cases  of  carcinoma  of  the  cervix  uteri,  and  of  the 
fundus  uteri  are  inoperable  at  the  time  that  they  are  seen  by 

1  Taylor,  "Cancer,  Its  Study  and  Prevention."     Philadelphia,  1915,  p.  157. 

7 


98  CANCER 

competent  surgeons;  that  is  they  have  passed  the  stage  when 
the  uterus  can  be  removed  with  any  hope  of  permanently  curing 
the  patient." 

Carcinoma  of  the  Breast.— Although  occurring  in  such  an 
accessible  region  there  is  no  means  of  knowing  just  when  the 
diseased  process  has  begun,  or  how  long  it  has  lasted  before  it  is 
seen  by  the  physician.  For  the  tendency  to  cancer  has  existed 
long  before  there  is  any  definite,  recognizable  inward  or  outward 
lesion;  the  process  has  unquestionably  begun  in  a  single  cell  or 
group  of  cells  of  microscopic  character,  and  some  time  has 
always  elapsed  before  a  tumor  has  formed  which  can  be  dis- 
covered by  palpation.  It  is  for  this  reason  that  surgeons  have 
been  urging  the  removal  of  every  tumor,  however  small,  in 
women  over  35  years  of  age,  lest  they  should  become  malignant. 
All  the  more  necessary  is  it  to  recognize  and  treat  instantly  and 
very  thoroughly  by  medical  measures,  each  and  every  breast  tumor, 
as  experience  has  abundantly  shown  that  under  the  correct 
dietary  and  medical  treatment  many  tumors,  which  had  been 
recognized  clinically  as  early  carcinoma  by  able  surgeons,  have 
disappeared  and  remained  absent  for  many  years,  as  will  appear 
later. 

The  first  symptom  of  carcinoma  which  attracts  the  attention 
of  the  patient  and  sooner  or  later  leads  one  to  seek  medical 
advice,  is  a  tumor,  in  three-quarters  of  the  cases.  This  is 
discovered  accidentally  by  the  patient,  often  in  bathing,  and 
may  be  very  small,  or  even  of  some  size  before  it  is  noticed. 
Quite  commonly,  perhaps  in  a  quarter  of  the  cases,  there  is  a 
little  darting  pain,  running  from  the  breast  to  the  shoulder  or 
down  the  arm,  just  enough  to  call  attention  to  the  developing 
lesion:  later,  of  course,  when  there  is  pressure  on  nerves  or 
oedema  of  the  arm,  the  pain  may  be  a  really  troublesome 
feature,  and  in  recurrent  cancer  of  the  breast,  after  operation, 
it  is  often  most  agonizing.  In  rare  cases  the  patient  will  first 
notice  an  axillary  adenopathy,  and  this  may  be  detected  by 
careful  manipulation  in  perhaps  fifty  per  cent  of  cases  when 
first  coming  for  treatment.     In  a  few  cases  retraction  of  the 


DIAGNOSIS  OF  CANCER  99 

nipple  will  be  the  first  sign  noticed,  and  still  more  rarely 
discharge  from  the  nipple. 

The  carcinomatous  tumor  is  by  no  means  easy  of  early 
recognition  with  certainty  in  quite  a  proportion  of  cases:  there 
are  always  chronic  mastitis,  cysts,  simple  adenoma,  fibro- 
adenoma, etc.,  etc.,  to  consider.  When  well  developed  there  is  a 
certain  hardness,  often  with  rather  sharp  nodular  margins  of 
the  tumor  mass,  which  are  quite  characteristic,  but  by  this 
time  there  is  commonly  also  adenopathy,  either  in  the  axilla 
or  in  the  anterior  pectoral  fold.  It  is  to  be  remembered, 
however,  that  lymphatic  glandular  enlargement  is  not  necessar- 
ily or  always  indicative  of  cancerous  infection,  for  the  glands 
are  often  enlarged  in  leukemia,  tuberculosis,  pus  infection, 
and  many  other  conditions.  When  the  lymph-nodes  in  the 
axilla  or  elsewhere  are  fixed,  their  diagnostic  value  is  of  greater 
importance  for  cancer,  or  when  the  supra  clavicular  glands  are 
palpable. 

Retraction  of  the  nipple,  when  the  growth  is  located  nearby, 
and  dimpling  of  the  skin,  or  "pig  skin"  appearance,  are  pretty 
certain  signs,  but  the  latter  may  occur  in  chronic  mastitis, 
tuberculosis,  and  syphilis.  Oedema  of  the  arm  is  a  late  sign, 
especially  after  operations,  and  may  prove  a  distressing  feature. 
When  ulceration  occurs,  later  in  the  disease,  the  diagnosis  of 
cancer,  of  course,  is  relatively  easy,  although  the  amount  and 
character  of  the  ulceration  vary  greatly  in  different  cases.  In 
some  it  may  be  soft  luxuriant,  bleeding  easily,  while  in  others 
there  is  a  brawny  hardness  around,  with  a  larger  or  smaller 
area  of  raw  surface;  when  extensive,  the  odor  is  commonly  very 
characteristic.  It  must  never  be  forgotten,  however,  that  a 
good  share  of  the  ulceration  and  pus  discharge  in  advanced 
cancer  is  largely  due  to  the  action  of  the  omnipresent  pus 
cocci,  which  find  a  suitable  nidus  for  their  development  and 
operation. 

As  the  disease  progresses,  with  greater  or  less  involvement  of 
other  parts,  there  are  many  symptoms  pointing  to  other  organs 
which  are  dependent  on  the  invading  carcinosis.     Thus,   by 


ioo  CANCER 

the  rather  ready  involvement  of  the  mediastinal  and  other 
lymphatic  glands,  there  will  be  cough  and  great  discomfort 
within  the  chest.  Neuritic  pains  in  the  neck  and  elsewhere 
occur,  from  pressure  or  involvement  of  the  nerve  sheaths. 
Bony  swelling  on  the  sternum  or  ribs,  with  much  pain  are  not 
uncommon.  Cachexia  develops  pretty  rapidly  after  the  disease 
has  reached  this  stage,  and  the  patient  dies  from  exhaustion. 

Since  breast  tumors  are  largely  a  law  to  themselves  a  study 
of  them  jointly  should  be  of  interest.  The  benign  growths  of 
younger  women  are  fibro-epithelial  and  are  circumscribed  or 
more  or  less  diffuse.  The  diffuse  form  or  ribro-adenoma  type, 
is  often  due  to  traumatism  and  is  known  to  follow  mastitis. 
These  benign  growths  have  all  the  properties  of  benign  tumors 
in  general,  but  the  rule  of  surgical  procedure  is  to  remove  them, 
and  their  removal,  with  microscopic  demonstration  of  benign- 
ity, is  sometimes  followed  by  the  development  of  true  carci- 
noma. Fibro-  or  adeno-sarcoma  may  show  anaplasia  in  the 
connective  tissue  with  tendency  to  malignancy.  The  proper- 
ties are  partly  those  of  benign  and  partly  of  malignant  growths 
— under  the  latter  head  is  rapid  growth.  For  these  the  breast 
is  commonly  amputated,  and  in  advanced  cases  the  complete 
cancer  operation  is  performed  and  recovery  is  then  expected,  but 
with  many  disappointments. 

The  corresponding  type  of  epithelial  tumor  is  the  cyst-ade- 
noma, which  is  said  to  present  a  type  of  cancerous  malignity 
of  low  grade  in  about  15  per  cent  only  (papillary  form  50  per 
cent).  According  to  circumstances,  as  in  fibro-sarcoma,  the 
breast  may  be  amputated  or  the  radical  cancer  operation  may 
be  performed,  and  as  in  the  preceding,  the  out  look  is  then  fairly 
good.  Compared  with  cancer  proper  these  tumors  are  rare. 
The  semi-benign  sarcoma  is  however  more  common  than  the 
typically  malignant  one. 

In  regard  to  cancer  of  the  breast  it  is  now  known  to  be  as 
common  in  the  negress  as  in  the  white  woman,  as  abundantly 
shown  in  statistics.  The  foreign  born  of  various  nationalities 
in  the  United  States  are  twice  as  commonly  affected  as  the 


DIAGNOSIS  OF  CANCER  IOI 

natives.  It  is  not  uncommon  in  the  Chinese,  and  Kerr  of  Canton 
did  1 1  breast  operations  in  a  year  out  of  30  cancer  operations  of 
all  kinds.  Cantlie  states  that  of  114  cases  of  cancer  in  native 
Chinese  38  were  mammary.  In  regard  to  heredity  this  has 
been  seen  in  as  high  as  t,^  per  cent,  although  in  other  material 
it  has  been  very  small.  The  element  of  heredity  affects  all 
breast  tumors,  including  those  of  the  male.  The  married 
woman  and  multipara  are  considerably  more  predisposed  than 
the  opposite  type,  as  is  the  woman  who  nurses  her  own  infants, 
and  some  very  high  percentages  are  given  for  those  predisposed. 
The  age  period  corresponds  with  the  involution  of  the  gland. 

The  general  average  of  histories  of  traumatism  is  only  about 
14  per  cent.  Although  it  is  often  stated  that  the  single  trauma 
tends  to  cause  sarcoma  and  not  cancer,  the  latter  has  some- 
times followed  at  once  upon  an  injury.  According  to  Gilliam  but 
one  case  in  400  arises  from  the  scar  left  by  an  injury.  In  male 
breast  cancer  the  element  of  trauma  is  not  to  be  ignored,  and 
there  seems  to  be  unanimity  that  trauma  is  a  prominent  factor, 
and  cancer  in  the  male  has  followed  the  absorption  of  hematoma 
from  a  bruise.  Mastitis  is  known  to  be  a  factor  in  both  sexes 
and  in  about  22  per  cent  there  is  a  direct  history  of  puerperal 
mastitis.  Cancer  has  frequently  arisen  in  the  scar  of  suppu- 
rative mastitis.  The  question  of  transition  of  benign  to 
malignant  is  a  vexed  one  here  as  elsewhere.  In  one  form  of 
cyst  adenoma,  known  as  the  papillary,  one-half  of  the  cases 
may  be  depended  on  to  become  malignant,  and  varying  lower 
percentages  in  others. 

The  encephaloid  cancer  of  old  authors  is  rare  and  appears  in 
younger  women,  and  the  disease  may  pursue  an  acute  course, 
simulate  mastitis,  and  even  suppurate.  The  longest  survival 
is  about  a  year,  and  metastases  occur  by  both  routes  at  an 
early  period.  " Simple  cancer"  makes  up  a  per  cent  of  15  or 
18,  and  the  two  forms  together  make  about  20  per  cent.  This 
form  is  midway  in  type  between  encephaloid  or  medullary  and 
scirrhous  cancer.  The  latter  is  attended  by  much  proliferation 
of  connective  tissue  which  retracts  and  compresses  the  epithelia, 


102  CANCER 

thus  limiting  their  proliferation.  This  may  perhaps  be  regarded 
as  a  natural  conservative  attempt  at  cure,  and  in  the  higher 
types  of  scirrhus  the  affection  is  often  brought  to  a  relative 
standstill.  This  form  seems  to  occur  by  preference  in  the 
feeble  or  slender,  elderly  subject.  It  is  in  these  cases  that  the 
knife  has  sometimes  done  harm  by  lighting  up  the  disease. 
Some  of  these  cases  bear  a  great  resemblance  to  chronic  atrophic 
mastitis. 

Malignant  adenoma  is  a  rarer  form  of  malignancy,  which 
gives  a  good  per  cent  of  operation  recoveries  because  the 
axillary  glands  are  seldom  involved.  Halsted  says  that  opera- 
tion cures  75  per  cent.  The  form  of  cancer  in  question  may 
be  traced  to  mastitis  and  benign  growths  in  many  cases. 

In  the  acute  cancer  of  the  breast  of  Volkmann  there  is  a  dis- 
tinction from  encephaloid,  because  both  forms  are  represented 
— there  may  be  an  acute  type  of  scirrhus  as  well.  As  a  rule 
mastitis  is  simulated  at  the  outset,  and  the  diagnosis  may  be 
very  difficult.  The  condition  is  very  rare.  Fever  may  be 
present  and  the  toxemia  is  profound  and  both  types  of  metasta- 
sis occur  early.  Moore  saw  a  case  run  its  entire  fatal  course 
in  2  weeks  and  others  are  on  record  which  took  but  2  or  3 
months  to  destroy  life. 

Incomplete  operations  have  sometimes  cured  early  cases  of 
cancer.  In  early,  nonadherent  cases  so  good  a  surgeon  as 
Warren  of  Boston  claims  but  17  per  cent  of  real  recoveries, 
while  in  adherent  cases  only  5  per  cent.  On  the  other  hand,  with 
the  axilla  not  yet  involved  Warren  claims  64  per  cent  cures 
(most  of  these  were  very  likely  examples  of  semimalignant 
cancer  or  tumors).  Bloodgood  admits  but  7  per  cent  recoveries 
when  the  axillary  glands  are  involved. 

After  high  claims  had  been  made  by  surgeons  of  3  years 
or  more  survival  Barker  traced  a  number  of  3  year  survivors, 
finding  that  30  per  cent  of  these  succumbed  to  cancer  sooner 
or  later.  Smith  traced  out  many  cases  of  operative  recovery, 
and  found  that  only  17  per  cent  of  alleged  cures  were  really 
cured  (Mastin  in  Wood's  Handbook). 


DIAGNOSIS  OF  CANCER  103 

Multiple  Primary  Cancer. — This  subject  is  of  great  import- 
ance, as  adherents  of  the  local  origin  state  that  such  cases 
would  be  much  more  common  if  cancer  were  constitutional; 
not  only  is  it  very  rare  but  in  some  of  the  cases  it  is  difficult  to 
show  that  one  of  the  tumors  is  not  secondary. 

Recently  a  double  primary  cancer — stomach  and  rectum — 
was  reported  by  Letulle  and  Jaquelin,  and  it  was  naturally  very 
difficult  to  disprove  the  claim  that  the  rectal  cancer  was  not 
secondary,  as  several  ways  of  transmission  are  known.  The 
patient,  a  man  of  6&,  died  only  11  days  after  admission  to  the 
clinic.  The  entire  wall  of  the  stomach  was  in  a  state  of  carcin- 
osis and  the  process  had  extended  along  the  peritoneum  to 
the  diaphragm,  pleura  and  lungs.  In  addition  gland  metas- 
tases involved  the  posterior  abdominal  nodes,  secondarily 
attacking  the  kidneys.  The  cancer  found  in  the  rectal  ampulla 
was  pronounced  primary,  despite  the  extensive  secondary 
deposits.  The  intestine  from  stomach  to  rectum  was  intact 
while  the  rectal  cancer  close  to  the  anus  was  extensive.  No 
path  could  be  discovered  for  the  secondary  involvement  of  the 
rectum,  through  abdominal  movements,  as  already  mentioned. 

Moreover,  the  two  cancers  were  of  different  type,  that  of 
the  stomach  showing  none  of  the  usual  cylindrical  epithelium, 
while  the  rectal  cancer  was  a  pure  cylindroma  which  presented 
the  same  type  of  cell  as  its  environment.  The  gastric  cancer 
showed  small  cells  and  extensive  colloid  degeneration.  The 
rectal  cancer  was  in  the  ulcerative  stage  and  was  associated 
with  a  marked  inflammatory  reaction;  but,  despite  this  none  of 
the  usual  metastases  of  rectal  cancer  were  discovered,  a  fact  of 
great  significance.  The  question  is  raised  as  to  whether  in 
multiple  primary  cancer  both  foci  or  all  foci  metastasize. 
Neither  peritoneal  or  lymphnode  metastases  having  occurred 
from  the  rectal  lesion,  this  might  be  regarded  as  evidence  of 
secondary  origin,  but  the  negative  evidence  and  histological 
differences  seem  to  leave  no  doubt  as  to  diagnosis. 

We  have  seen  that  cancer  shows  every  sign  of  being  a  consti- 


104  CANCER 

tutional  affection,  in  which,  as  in  gout  or  rheumatism,  the 
actual  manifestation  of  the  disease  begins  in  some  one  location, 
as  when  the  great  toe  is  stepped  on  or  bruised.  In  carcinoma 
the  disordered  cells  of  a  part  produce  a  center  of  malignant 
tissue,  and  these  diseased  cells  seem  to  have  acquired  the 
property  of  continuing  their  mad  career  and  inducing  other 
neighboring  cells  to  take  on  the  same  action  until  a  tumor  is 
formed,  the  local  product  of  the  disease  carcinosis,  and  to  this 
local  lesion  we  give  the  name  of  cancer.  This  sequence  of 
events  is  best  illustrated  in  cancer  of  the  tongue  and  buccal 
cavity,  where  from  an  innocent  abrasion  of  the  mucous  mem- 
brane by  a  ragged  tooth,  there  will  develop  a  malignant  mass, 
which,  if  wrongly  treated,  or  even  left  alone,  progresses  with 
fearful  certainty  to  the  destruction  of  life.  It  is  as  irrational 
to  believe  cancer  to  be  a  purely  local  disease,  and  that  a  blow 
on  the  breast  or  prolonged  irritation  of  any  kind  anywhere  can 
induce  true  cancer,  without  an  underlying  constitutional  cause, 
as  it  is  to  believe  that  stepping  on  the  great  toe  can  induce  an 
attack  of  gout,  although  this  occurrence  may  be  the  first  sign 
which  leads  to  the  recognition  of  the  gouty  state. 


CHAPTER  VII 
PROGNOSIS  OF  CANCER 

When  left  entirely  to  itself,  and  under  unfavorable  circum- 
stances, the  prognosis  of  cancer,  in  any  and  all  locations,  is 
most  distressing,  and  most  authorities  agree  that,  unless  the 
patient  is  carried  off  otherwise,  90  per  cent  of  those  once  attacked 
with  cancer  succumb  to  the  disease,  whether  treated  or  not: 
and,  as  has  been  mentioned,  all  statistics  show  that  the  mor- 
tality of  the  disease  has  been  steadily  rising  in  every  country, 
especially  during  the  past  20  years  of  increasing  surgical 
activity. 

Fortunately  the  United  States  statistical  report  for  1918 
shows  that  the  mortality  for  that  year  had  fallen  a  trifle,  so  that 
it  was  79.8  persons  in  the  100,000  population,  against  81.6  in 
191 7;  due  perhaps  to  greater  enlightenment  in  regard  to  the 
medical  versus  the  surgical  treatment  of  the  disease. 

The  prognosis  of  cancer  varies,  of  course,  very  greatly  with 
the  case,  the  location  of  the  disease,  its  duration  before  treat- 
ment, and  the  method  and  skill  employed.  As  thus  far  the 
reports  are  mainly  in  regard  to  surgery,  and  latterly  radium  and 
#-ray,  and  as  these  reports  are  often  so  conflicting,  it  is  very 
difficult  to  give  briefly  what  may  reasonably  be  expected  in 
regard  to  the  disease  as  it  affects  various  regions.  For  as  yet 
there  are  no  reliable  data  as  to  the  relative  mortality  of  cases 
under  medical  treatment.  But  Dr.  J.  Aebli1  by  tabulating  the 
cancer  mortality  in  Switzerland,  between  1900  and  1915,  and 
for  23  years  before,  gives  us  some  idea  of  the  natural  course  of 
of  the  disease  in  general.  His  tabulated  cases  of  those  patients 
who  had  been  operated  on,  and  those  left  under  ordinary 
medical,  not  special,  treatment,  show  apparently  that  opera- 
tive procedures  either  lessen  the  life  expectancy  or  have  such  a 
'Aebli.     Schweitz.  Med.  Wochenschr.,  October  14,  1920. 

105 


106  CANCER 

slight  influence  in  prolonging  life,  that  it  may  be  regarded  as 
negligible.  How  far  a  properly  guided  medical  treatment  may 
affect  prognosis  will  appear  later. 

As  already  stated  we  exclude  epithelioma  of  the  skin,  which 
commonly  yields  such  excellent  results,  especially  when  taken 
early  and  rightly,  under  quite  a  variety  of  external  measures, 
and  from  which  local  disease  no  judgment  should  be  made 
regarding  true  cancer  affecting  deeper  organs. 

Cancer  of  the  breast,  which  is  the  most  accessible  of  these 
latter,  both  for  early  recognition  and  radical  treatment,  should 
afford  perhaps  the  best  field  for  estimating  the  prognosis  of  the 
disease,  and  here  we  may  abstract  from  Ewing,1  an  unpreju- 
diced, scientific  student.  After  quoting  reported  statistics  of 
recurrences  occurring  from  7  to  25  years  after  operation,  and 
referring  to  the  occasional  later  appearance  of  the  disease  in  the 
other,  unoperated  breast,  and  the  statement  that  the  average 
duration  of  life  in  untreated  cases  was  placed  by  Paget  at  4  years 
by  Odekop  at  29  months,  and  by  Sprengel  at  27  months,  he 
says: 

"1.  The  figures  (4  years — 27  months)  are  too  divergent  to 
permit  accurate  conclusions  regarding  the  natural  duration  of 
mammary  cancer.  The  attempt  to  establish  an  average 
duration  of  this  disease  should  be  replaced  by  the  systensic 
classification  of  cases,  according  to  the  factors  known  to 
influence  prognosis. 

"2.  The  comparison  of  operated  and  unoperated  cases  is 
sophistical.  The  choice  of  operable  cases  tends  to  throw  into 
the  untreated  class  the  majority  of  rapid  and  unfavorable  cases. 

"3.  Statistics  favor  the  conclusion  that  operation  in  the  whole 
shortens  life  in  recurrent  cases,  although  sometimes  rendering 
it  more  tolerable.  Handley's  recurrent  cases  lived  29.6  months, 
while  in  the  above  series  the  duration  of  life  was  27,  29,  34,  and 
48  months  respectively.  This  conclusion  is  strengthened  by 
theoretical  considerations,  as  well  as  by  observations  on  the  rapid 
course  of  many  recurrent  cases.     It  is  clearly  proven  in  many 

1  Ewing,  "Neoplastic  Diseases."     Philadelphia,  1919,  pp.  521,  522. 


PROGNOSIS  OF  CANCER  107 

instances  by  the  increasing  anaplasia  exhibited  in  the  structure 
of  recurrent  cases. 

"4.  The  high  proportion  of  clinical  cures  from  the  modern 
operation  has  resulted  largely  from  the  earlier  recognition  of 
cancer,  and  the  inclusion  of  a  large  number  of  minute  carcinomas 
or  precancerous  lesions  in  the  operated  class. 

"5.  The  choice  of  therapeutic  measures  should  not  be  made 
under  the  impression  that  the  duration  of  the  untreated  cases 
is  27  months,  and  that  40  per  cent  of  the  operated  cases  are 
cured.  Since  the  duration  of  the  disease  may  vary  from  16 
weeks  to  25  years,  and  the  favorable  results  of  operation  from 
o  to  100  per  cent,  the  first  essential  in  treatment  is  accurate 
diagnosis  and  prognosis  of  each  individual  case. 

"6.  In  estimating  the  economic  importance  of  the  surgical 
treatment  of  mammary  cancer  there  must  be  charged  up  the 
cost  of  acquiring  surgical  skill,  and  the  deplorable  conditions 
following  local  recurrence.  There  can  be  no  doubt  that  opera- 
tion shortens  life  and  aggravates  the  terminal  suffering  in  the 
great  majority  of  recurrent  cases.  Most  of  those  who  deal 
with  the  great  number  of  these  unfortunate  patients  would 
welcome  a  judicious  limitation  of  the  scope  of  operability  in 
this  disease. 

"From  clinical  and  pathological  studies  I  have  drawn  the 
impression  that  in  dealing  with  mammary  cancer  surgery  meets 
with  more  peculiar  difficulties  and  uncertanities  than  with  almost 
any  other  form  of  the  disease.  The  anatomical  types  of  the 
disease  are  so  numerous,  the  variations  in  clinical  course  so 
wide,  the  paths  of  dissemination  so  free  and  diverse,  the 
difficulties  of  determining  the  actual  conditions  so  complex, 
and  the  sacrifice  of  tissue  so  great,  as  to  render  impossible  in  a 
majority  of  cases  a  reasonably  accurate  adjustment  of  means  to 
ends. 

"The  scope  of  the  operative  field  having  apparently  reached 
a  limit,  the  chief  hope  for  a  reduction  in  the  mortality  from 
mammary  carcinoma  lies  in  its  prevention  and  earlier  diagno- 
sis."    Most  of  those  who  have  had  the  best  opportunity  of 


108  CANCER 

watching  cancer  for  many  years,  especially  its  recurrences,  will 
I  think,  agree  with  Dr.  Ewing  in  his  judgment. 

Carcinoma  of  the  Uterus. — Here  also,  in  the  case  of  cervical 
carcinoma,  which  forms  over  80  per  cent  of  the  cases,  one  would 
expect  that,  from  the  relative  ease  of  an  early  diagnosis  of  the 
cervix  by  inspection,  and  the  comparative  accessibility  of  the 
diseased  tissue,  the  prognosis  would  be  correspondingly  good. 
But  there  are  no  data  accessible  to  show  the  natural  duration 
of  cancer  in  this  region,  because  in  so  large  a  proportion  of  the 
cases  the  disease  is  neglected  until  it  has  attained  formidable 
proportions.  Taylor1  states  that  "Probably  75  per  cent,  at 
least  of  the  cases  of  carcinoma  of  the  cervix  uteri  and  of  the 
fundus  uteri  are  inoperable  at  the  time  that  they  are  seen  by 
competent  surgeons;  that  is,  they  have  passed  the  stage  when 
the  uterus  can  be  removed  with  any  hope  of  permanently 
curing  the  patient." 

Ewing2  states:  "The  mortality  from  uterine  cancer  is  very 
high.  Jacobson,  from  an  elaborate  analysis,  shows  that  of  the 
women  who  enjoy  the  services  of  the  best  American  operators, 
35  per  cent  are  inoperable,  the  operative  mortality  is  15.17  per 
cent:  after  5  years,  8.39  per  cent  are  well,  and  1  per  cent  of  the 
total  are  permanently  cured  .  .  .  From  the  economical 
standpoint  it  must  be  considered  that  a  competent  Wertheim 
operation  is  beyond  the  reach  of  a  great  majority  of  the  popu- 
lation, and  that  all  the  phases  of  the  cost  of  acquiring  technical 
skill  should  be  counted  in  estimating  its  utility.  Because  of 
these  considerations  a  marked  change  has  occurred  during  the 
last  few  years  in  the  aspects  of  surgical  treatment  of  uterine 
cancer,  most  surgeons  preferring  to  reduce  the  scope  of  oper- 
ability,  and  others  abandoning  operations  for  uterine  cancer,  in 
favor  of  radium  and  x-ray  treatment." 

Cancer  of  the  Lip. — In  this  situation  also  the  lesion  is  readily 
seen  and  accessible  for  operation,  and  the  prognosis  varies 
immensely  with  the  case,  and  the  time  and  character  of  the 

1  Taylor,  "Cancer,  its  Study  and  Prevention."    New  York,  1915,  p.  157. 

2  Ewing,  loc.  cit.,  p.  541. 


PROGNOSIS  OF  CANCER  109 

treatment.  The  reports  of  different  operators  also  differ 
greatly,  according  as  they  relate  to  early  or  late  cases.  While 
some  claim  that  there  are  not  over  25  per  cent  of  permanent 
cures  of  all  cancers  in  this  location,  others  who  take  only  early 
cases  claim  as  high  as  90  per  cent,  which  is  undoubtedly  extrava- 
gant. When  left  entirely  alone,  and  constantly  exposed  to  the 
ordinary  irritation  of  smoking,  eating  and  drinking,  and  atmos- 
pheric influences,  the  disease,  when  once  developed,  tends  very 
certainly  to  a  steady  increase  until  it  is  entirely  inoperable ;  but 
if  protected  or  carefully  handled  it  may  be  quiescent  even  for 
some  years.  Under  most  careful  medical  treatment,  external 
and  internal,  many  cases  of  unquestioned  early  cancer  of  the 
lip  subside  entirely,  and  remain  well  indefinitely,  as  we  have 
repeatedly  observed,  even  the  enlarged  glands  disappearing. 
It  is  recognized  that  early  surgical  operations  on  the  lip  are 
successful  in  proportion  to  the  care  exercised  in  removing 
lymphatic  glands  which  are  or  may  become  affected.  Much 
has  been  claimed  for  radium,  and  also  #-rays,  but  end  results 
after  a  lapse  of  time  have  not  been  generally  reported. 

Cancer  of  the  Tongue  and  Mouth. — Here  again  the  lesions 
which  are  or  may  become  cancerous  are  easy  of  inspection  and 
moderately  accessible  for  operation,  but  the  prognosis  is  far 
from  satisfactory.  When  left  alone,  Butlin  says  that  there  is 
but  one  end,  death.  Ewing  states  that  "The  clinical  course  of 
buccal  cancer  is  usually  progressive  and  terminates  fatally  in  an 
average  period  of  2  years."  "More  rapid  courses  are  commonly 
observed  in  lingual  cases,  6  to  12  months,  and  in  tonsillar  6  to  10 
months."  Taylor  says  that  the  end  results  of  operation  are 
unsatisfactory,  the  chance  is  less  than  for  epithelioma  in  most 
other  locations.  The  immediate  operative  mortality  is  very 
large,  even  up  to  25  to  36  per  cent  by  some  operators,  but  the 
best  modern  surgery  has  reduced  this  very  considerably.  As 
will  be  seen  later  most  careful  medical  treatment  can  hold  the 
disease  in  check  for  a  long  period,  and  obtain  a  certain  fair  per- 
centage of  cures.  However  radical  the  operation,  the  lymphatic 
connections  in  this  locality  are  so  enormous  and  deep,  that  even 


no  CANCER 

if  the  disease  does  not  recur  in  the  previous  site,  sooner  or  later 
it  may  appear  in  the  glands,  with  ulceration  and  great  distress. 
Radium  promises  better  results  than  surgery  in  many  of  the 
cases  of  cancer  of  the  tongue  and  buccal  cavity,  but  very  careful 
and  complete  medical  treatment,  with  the  addition  of  radium, 
can  accomplish  more,  as  will  be  seen  in  a  later  chapter. 

Cancer  of  the  Alimentary  Tract. — The  prognosis  varies  very 
greatly  with  the  location  of  the  trouble,  the  period  at  which  it 
is  discovered  and  treated,  and  the  treatment  employed.  The 
United  States  report  for  1918,  gives  a  mortality  from  cancer  of 
the  intestines  at  6.7  persons  per  100,000,  against  6.8  persons  in 
191 7.  Unchecked  the  disease  in  every  location  tends  to  a  fatal 
termination,  and  unfortunately  the  statistics  furnished  by  sur- 
gery are  far  from  encouraging.  There  are  no  statistics  avail- 
able as  to  the  average  duration  of  life  in  these  cases,  partly  for 
the  reason  that  it  is  next  to  impossible  to  determine  with  cer- 
tainty just  when  the  diseased  process  begins,  and  a  very  con- 
siderable proportion  of  the  cases  have  already  advanced  so  far 
when  seen  by  the  surgeon,  that  they  are  practically  inoperable; 
the  immediate  operative  mortality  is  high  in  many  locations, 
even  up  to  50  per  cent.  Cancer  of  the  large  intestine  is  apt  to 
be  less  malignant,  and  with  better  end  results  than  in  the  small 
intestine :  it  is  stated  by  Taylor  that  the  average  course  of  car- 
cinoma of  the  large  intestine,  without  operation,  is  from  2  to  4 
years,  but  malignant  cases  may  terminate  fatally  in  6  months. 
The  best  modern  surgery  has  reduced  the  operative  mortality 
very  considerably.  The  average  duration  of  life  after  the 
formation  of  an  artificial  anus  is  stated  to  be  approximately  one 
and  a  half  years. 

Carcinoma  of  the  Rectum. — The  prognosis  of  cancer  in  this 
locality  is  very  unfavorable.  The  operative  mortality  of  all 
cases  is  stated  to  be  from  15  to  20  per  cent,  and  recurrence  after 
operation  is  not  infrequent. 

Cancer  of  the  Stomach. — It  is  difficult  to  secure  any  adequate 
data  regarding  the  prognosis  of  cancer  of  the  stomach,  except 
the  statement  that  it  is  fatal  in  from  2  to  4  years,  when  not 


PROGNOSIS  OF  CANCER  in 

operated  on,  and  that  the  number  of  patients  thus  treated  who 
are  permanently  cured  is  small,  although  the  total  number  of  cases 
is  very  great,  and  steadily  increasing.  In  the  United  States 
Report  for  1914,  there  were  12,768  deaths  from  this  cause,  or 
19.3  persons  per  100,000,  and  in  the  1918  Report  the  number 
was  15,844,  or  19.4  persons  per  100,000  population.  As  in  so 
many  other  situations  the  definite  symptoms  of  cancer  which 
warrant  interference  are  so  uncertain,  and  the  disease  is  so  slow 
in  fully  establishing  itself,  that  in  most  instances  there  has 
already  occurred  such  an  involvement  of  the  lymphatics,  liver, 
and  other  organs,  that  by  the  time  the  patient  sees  a  competent 
surgeon  it  is  practically  too  late  to  expect  a  permanent  cure  of 
the  disease.  Ewing  has  collected  data  respecting  curability  by 
surgical  procedure,  and  expresses  the  opinion  that  "of  selected 
operable  cases  about  20  per  cent  may  be  surgically  cured."  But 
he  gives  also  other  less  favorable  statistics,  where  of  480  opera- 
tions only  8  patients  were  known  to  be  alive  after  3  or  4  years, 
quoting  also  Friedenwald,  who  reports  "from  1,000  cases,  266 
operations,  138  exploratory,  9  gastrectomies,  one  living  over 
18  months,  but  all  dying  of  the  disease."  Advanced  surgery 
has  reduced  the  operative  mortality  from  68  per  cent  to  35,  25, 
17,  and  even  13  per  cent  has  been  claimed. 

Cancer  of  the  Liver  and  Gall  Bladder. — Here  the  prognosis  is 
even  more  unfavorable,  4  to  6  months  is  stated  as  the  duration  of 
life  with  primary  cases  of  the  liver,  but  in  secondary  involvement 
the  progress  may  be  much  slower:  practically  no  operations  are 
feasible.  Cancer  of  the  gall  bladder  is  said  to  terminate  in  from 
6  months  to  a  year  after  it  has  become  established,  and  while 
occasionally  operated  on  there  are  very  few  cures,  except  in  cases 
where  carcinoma  has  been  discovered  accidentally  in  removing 
gall  stones. 

Carcinoma  of  the  Kidney. — Here  the  prognosis  is  also  most 
unfavorable,  not  only  is  the  operative  mortality  high,  but  there 
are  many  deaths  from  metastases,  although  some  fully  success- 
ful cases  are  reported. 


112  CANCER 

Carcinoma  of  the  Bladder  and  Prostate. — In  these  cases  the 
prognosis  depends  upon  the  extent  of  the  growth  before  oper- 
ation. Small  papillomatous  cancers  of  the  bladder  can  often 
be  removed  successfully,  both  by  complete  surgical  operation 
and  by  careful  use  of  the  high  frequency  current.  It  is  stated 
that  the  average  duration  of  life  after  the  first  symptoms  of 
carcinoma  of  the  bladder  is  under  3  years.  In  carcinoma  of  the 
prostate  Taylor  says  "This  is  unfavorable  even  if  the  case  is 
seen  at  an  operable  stage.  In  most  cases  there  is  an  early  recur- 
rence. There  is,  however,  definite  prolongation  of  life  and  an 
increase  of  comfort,  obtained  by  operation  in  many  cases." 

In  studying  the  prognosis  of  cancer  one  is  struck  with  the 
similarity  of  statements,  just  as  in  the  case  of  the  histo-patho- 
logy  of  the  disease  in  various  locations.  Cancer  wherever  situ- 
ated is  one  and  the  same  disorderly  and  virulent  action  of  certain 
cells  of  the  body,  mainly  of  the  epithelial  elements,  which  when 
left  to  itself  tends  to  a  fatal  termination  in  a  period  from  a  few 
months  to  a  few  years.  In  every  location  it  is  acknowledged 
that  the  surgical  excision  of  a  diseased  portion,  with  more  or  less 
removal  of  adjoining  parts  and  lymphatics,  has  relatively  little 
to  do  with  really  checking  the  progress  of  the  disease,  while  the 
operative  mortality  varies  from  10  to  50  or  more  per  cent, 
according  to  the  location  and  severity  of  the  process  when  oper- 
ated on,  with  some  other  factors. 

We  have  also  seen  that  recurrences  in  situ  or  involvement  of 
other  organs  or  lymphatics  is  the  rule  rather  than  the  exception. 
While  most  of  these  unfortunate  occurrences  take  place  largely 
in  the  first  year  or  so,  there  are  plenty  of  recorded  instances  of 
recurrences  (or,  more  properly,  new  developments  of  cancer,) 
in  all  succeeding  years,  even  as  late  as  25  years  after  surgical 
interference. 

It  is  recognized  that  the  aims  of  surgery  in  regard  to  cancer 
are:  1.  To  cure  the  disease:  2.  To  prolong  life:  3.  To  relieve 
symptoms. 

In  regard  to  the  first  it  is  more  and  more  acknowledged, 


PROGNOSIS  OF  CANCER  11.3 

both  by  physicians  and  surgeons,  that  the  surgical  removal  of 
the  affected  parts  does  not  and  cannot  reach  the  real  cause  of  the 
trouble,  which  all  assert  to  be  unknown.  Moreover,  the  steadily 
rising  death  rate  up  to  90  per  cent  of  those  once  affected,  shows 
the  futility  of  the  attempt. 

In  regard  to  the  prolongation  of  life  by  operation,  we  have 
mentioned  the  study  by  Aebli,  that  after  an  analysis  of  a  large 
number  of  cases  treated  surgically  and  those  left  with  ordinary 
treatment,  that  the  advantage  of  the  knife  cases  is  inconsider- 
able, and  that  of  Ewing  that  secondary  operations  in  cancer  of 
the  breast  shorten  life,  while  the  pain  and  agony  of  later 
recurrences  is  often  beyond  description. 

As  to  the  relief  of  symptoms  by  operation,  this  is  conceivable 
in  a  small  proportion  of  instances,  but  those  who  have  had  the 
opportunity  of  seeing  large  numbers  of  post-operative  recur- 
rences will  testify  that  the  subsequent  distress  from  them  quite 
overbalances  any  relief  received  in  the  few  successful  ones. 
Complete,  careful,  and  long  continued  dietary,  hygienic,  and 
medicinal  treatment  answers  all  of  these  purposes  far,  far  better, 
as  will  be  shown  in  succeeding  chapters. 


CHAPTER  VIII 
METASTASIS  OF  CANCER 

While  cancer  is  not  infectious  or  contagious,  and  while 
human  cancer  cannot  be  inoculated  on  another  human  subject, 
or  on  animals,  the  disease,  first  manifested  in  a  single  spot  can 
be  spread  and  is  spread  by  metastasis  in  the  same  individual 
to  an  almost  indefinite  extent,  until  there  is  a  general  carcinosis 
which  is  fatal.  For  cancer  is  not  a  local  affection,  the  lesion  or 
mass  to  which  we  give  the  name  of  cancer  being  only  the  local 
manifestation  or  product  of  an  antecedent  and  long  continued 
systemic  derangement,  just  as  are  those  of  rickets,  arthritis 
deformans,  arteriosclerosis,  gout,  etc. 

This  extension  or  development  of  the  disease,  cancer,  can 
occur  in  four  ways:  First,  by  recurrence  in  or  near  the  site  of 
an  operation ;  Second,  by  what  is  known  as  metastasis,  spreading 
the  disease  to  distant  parts  and  organs,  through  the  lymphatics 
or  blood  vessels;  Third,  by  a  continuance  of  action  of  the  same 
abnormal  blood  condition  which  induced  the  first  vicious 
aberration  of  previously  normal  body  cells,  causing  them  to 
produce  new  or  fresh  neoplastic  growths,  instead  of  forming 
healthy  tissue;  and  Fourth,  by  a  certain  hormone,  or  poisonous 
something  given  off  by  already  existing  cancer  cells,  which  aids 
in  exciting  other  cells  to  cancerous  action.  The  latter  of  these 
agencies  has  been  considered  in  the  chapter  on  the  bio- 
chemistry of  cancer;  the  first  three  are  frequently  confounded, 
but  are  distinct,  though  closely  connected. 

Recurrence  in  or  near  the  site  of  an  operation  indicates 
simply  that  there  has  been  an  incomplete  removal  of  all  the 
morbid  tissue,  although  the  remaining  portion  may  be  micro- 
scopic. The  impossibility  of  determining  absolutely  the  utmost 
extent  of  the  original  lesion,  and  reaching  and  removing  all 
possible  lymphatic  involvements,  accounts  for  the  redevelop- 

114 


METASTASIS  OF  CANCER  115 

ment  of  the  disease;  for  it  is  recognized  that  even  single, 
minute  cancer  cells  have  the  power,  under  existing  conditions 
of  the  blood,  to  reproduce  their  like  and  renew  the  disease  in 
any  location.  Rough  handling  of  tumors  before  or  during 
operating  may  force  cancer  cells  into  lymphatics,  and  the  opening 
of  main  lymphatics  and  blood  vessels  during  operation  is  also 
a  source  of  the  spread  of  the  disease. 

Metastasis  is  undoubtedly  the  cause  or  means  of  disseminat- 
ing cancer,  by  transferring  microscopic  cells  which  have  taken 
on  a  cancerous  action  to  distant  sites,  where  they  pursue  their 
rampant  and  vicious  course,  inciting  the  same  action  in  adjoining 
cells. 

These  cancer  cells  are  scattered  through  the  body  by  1. 
The  lymphatic  system;  2.  The  venous  system;  and  3.  The 
arterial  system;  of  these  the  lymphatic  system  is  generally  the 
first  point  of  entry,  although  they  may  gain  access  also  directly 
through  the  others.  A  good  knowledge  of  the  distribution  and 
structure  of  the  lymph  capillaries,  with  their  single  layer  of 
endothelial  cells,  and  the  lymph-nodes,  will  aid  greatly  in  under- 
standing the  subject  of  metastasis  in  cancer.  The  enormous 
and  most  intimate  relation  of  the  lymphatics  to  all  the  struc- 
tures and  to  every  cell  in  the  body,  and  the  immense  numbers 
of  lymphatic  glands,  both  external  and  deep,  together  with  the 
functions  they  perform  normally,  in  their  effort  to  protect  the 
health  of  the  individual,  explain  how  readily  they  become 
affected  in  cancer,  and  how  natural  it  is  for  metastastic  proc- 
esses to  take  place  through  them. 

In  studying  the  histo-pathology  of  cancer  we  have  seen  that 
its  morbid  cells  have  no  respect  for  anatomical  divisions,  but 
have  the  power  to  induce  neighboring  cells  of  any  tissue  to 
join  in  their  mad  career.  As  the  lymphatics  have  as  one  of 
their  functions  to  carry  away  the  results  of  catabolism  from  the 
tissues  of  the  body,  these  minute  carcinomatous  cells,  or  emboli, 
are  readily  carried  along  until  stopped  by  the  nearest  small 
lymphatic  gland,  even  as  pus  cells,  or  tuberculous  or  other 
elements  are  arrested.     But  the  lymphatic  gland  suffers  in  its 


Il6  CANCER 

struggle  to  prevent  them  from  passing  into  the  blood.  It  is 
believed  that  the  glands  do  succeed  in  destroying  some  pro- 
portion of  the  cancer  cells,  but  commonly  the  task  is  too  great, 
and  the  activity  of  the  retained  cancerous  elements  overcomes 
their  resistance,  they  pass  on  and  succeeding  glands  are  affected, 
until  ultimately  the  tumor-cell  particles  are  carried  on  into 
the  left  or  right  thoracic  duct,  and  thus  reach  the  circulating 
venous  blood.  As  this  passes  through  the  lungs  the  lymphatic 
glands  there  try  to  arrest  them,  and  the  cancerous  mediastinal 
and  supra-clavicular  nodes  result.  As  cancerous  particles  pass 
through  the  capillaries  they  lodge  in  the  skin  and  elsewhere, 
and  create  foci  for  the  development  of  the  disease. 

Carcinoma  may  also  grow  directly  into  the  lumen  of  a  blood 
vessel,  and  cancer  cells  may  be  washed  off  into  the  general 
circulation.  But  the  argument  is  advanced  that  if,  cancer  were 
mainly  distributed  through  the  vascular  system  there  would  be  a 
more  general  and  sudden  outburst  of  cancerous  lesions  all  over 
the  body.  Some  believe  that  the  blood  has  certain  cytolytic 
powers,  which  destroy  a  portion  at  least  of  these  elements  in  its 
current.  But  the  weight  of  proof  is  mainly  that  cancer  is  dis- 
tributed through  the  lymphatic  system.  In  certain  cases  a 
neo-plastic  process  will  ulcerate  through  a  vein,  and  thus  give 
an  abundant  supply  of  infectious  material. 

Quoting  Ewing:  "In  cancer  of  the  breast  Handley  has  shown 
that  there  may  be  continuous  extension  of  tumor  cells  through 
the  lymphatics  of  the  deep  pectoral  fascia  to  the  axillary  and 
supra-clavicular  nodes ;  thence  to  overlying  skin  and  to  humerus ; 
through  the  deep  lymphatics  to  the  ribs,  pleura,  lung,  and  spine; 
across  the  chest  wall  to  the  opposite  breast;  downward  through 
the  abdominal  wall  to  the  epigastric  regions,  and  thence  by  the 
falciform  ligament  to  the  liver;  and  further  to  the  inguinal 
region  with  involvement  of  lymph-nodes,  skin,  and  femur. 
Invasion  of  the  humerus  occurs  at  the  deltoid  insertion,  and  of 
the  femur  at  the  trochanter,  where  these  bones  are  closest  to  the 
skin,  through  the  deep  lymphatics  of  which  the  bone  invasion 
follows.     The  lower   leg  and  forearm  bones  escape  infection, 


METASTASIS   OF   CANCER  117 

which  is  inconsistent  with  an  embolic  origin  through  blood 
vessels. 

"Passing  through  the  deep  lymphatics  of  the  chest  and  ab- 
dominal wall  the  cells  enter  the  pleura  and  peritoneum,  and  be- 
come implanted  on  the  serous  surfaces,  and  produce  superficial 
infiltrations  of  the  lung,  liver,  intestines,  and  ovary.  Or  the 
viscera  may  be  invaded  through  their  main  lymphatic  vessels, 
giving  central  tumors.  The  liver  is  involved  through  the  lym- 
phatics of  the  falciform  and  round  ligaments,  or  by  transperito- 
neal implantation,  or  by  way  of  portal  nodes;  the  lung  by  trans- 
pleural implantation  or  through  bronchial  nodes  and  hilus. 
Abdominal  invasion  by  the  epigastric  route  is  earlier  and  more 
frequent  than  the  thoracic,  occurring  without  thoracic  lesions 
in  12  per  cent  of  all  cases.  The  diaphragm  is  invaded  by  the 
epigastric  peritoneal  route,  and  through  the  descending  lym- 
phatics of  its  crura  the  retroperitoneal  nodes  and  kidneys  are 
attacked.  This  process  of  lymphatic  permeation  Handley 
believes  is  the  master  process  of  general  dissemination  of  cancer." 

Ewing  does  not  wholly  endorse  the  Handley  permeation 
theory  of  cancer,  namely,  that  cancer  cells  grow  along  the  lym- 
phatic vessels  centrifugally,  by  which  means  the  cells  excite 
around  the  lymphatics  an  inflammatory  reaction,  which  may 
result  in  the  destruction  of  the  cancer  cells  and  the  replace- 
ment of  the  lymphatic  by  a  fibrous  band. 

Quoting  Ewing  further:  "The  frequency  of  lymph-node 
metastases  varies  with  different  tumors,  with  different  varieties 
of  the  same  tumor,  and  with  different  positions  of  the  tumor  in 
the  same  organ,  and  must  be  separately  considered  for  each 
case.  Cancer  of  the  breast  probably  stands  high  in  the  list, 
very  few  malignant  cases  of  this  disease  failing  to  involve  the 
nodes,  if  allowed  to  remain  more  than  a  few  months.  Williams 
found  the  nodes  involved  in  73  per  cent  of  118  cases  at  first 
examination,  and  in  90  per  cent  of  44  autopsies. 

"Epithelioma  of  the  tongue  or  tonsil  very  early  and  nearly 
constantly  invades  the  lymph-nodes,  but  here  again  the  type  of 
the  tumor  is  the  determining  factor.     Williams  recorded  83  per 


Ii8  CANCER 

cent  of  104  lingual  cases  infected  at  the  first  examination,  and 
almost  100  per  cent  of  cases  coming  to  autopsy.  Epithelioma 
of  the  lower  lip  invades  the  lymph-nodes  more  slowly,  but  eventu- 
ally in  almost  all  cases.  In  186  cases  of  cancer  of  the  stomach 
examined  at  autopsy  by  Moore,  Cuneo,  and  Colwell,  lymph- 
nodes  were  involved  in  149. 

"The  lymph-nodes  escape  in  many  cases  of  uterine  cancer,  espe- 
cially with  tumors  of  the  fundus.  Epithelioma  of  the  skin  is 
slow  in  reaching  the  lymph-nodes,  and  rodent  ulcer  and  adenoid 
cystic  epithelioma  are  remarkable  for  the  long  or  permanent 
immunity  of  adjoining  lymph-nodes.  Of  34  malignant  tumors 
of  the  testis,  Butlin  found  the  lymph-nodes  free  in  only  3,  but 
in  a  series  of  19  cases  I  found  several  which  had  not  attacked  the 
inguinal  nodes.  The  tumor  usually  affects  first  the  epigastric 
nodes. 

"Changes  in  lymph-nodes  draining  malignant  tumors  show 
that  the  implantation  of  metastases  is  preceded  by  a  preparation 
of  the  soil.  For  weeks  or  months  before  the  actual  tumor  inva- 
sion the  regional  lymph-nodes  may  be  moderately  swollen. 
During  this  period  many  new  lymph-nodes  may  develop  in  the 
course  of  the  vessels.  On  section  the  swollen  lymph-nodes  show 
diffuse  hyperplasia  with  catarrhal  exfoliation  of  sinus  epithelium, 
or  multiplication  of  follicles.  It  is  not  uncommon  also  to  find 
the  nodes  atrophic  and  fibrous,  or  extensively  invaded  by  fat 
tissue,  conditions  which  reduce  their  effectiveness  as  filters. 
Owing  to  a  variety  of  causes  old  changes  of  the  latter  class  may 
permit  the  passage  of  cancer  cells  through  or  around  a  given 
group,  only  to  lodge  in  a  more  central  area.  The  former  class 
of  recent  alterations  must  be  referred  to  the  absorption  of  toxic 
products  from  the  tumor,  autolytic  and  bacterial.  There  are 
no  specific  histologic  features  of  the  precancerous  condition  of 
the  lymph-nodes,  but  there  are  reasons  to  believe  that  regressing 
tumor  cells  may  be  found  in  the  sinuses  before  definite  implanta- 
tion has  occurred.  As  previously  noted,  Kuster  found  that  in 
only  2  of  117  cases  were  the  axillary  nodes  which  were  removed 
with  breast  cancer  free  from  invasion. 


METASTASIS  OF  CANCER  1 1 9 

"The  earliest  nodules  appear  in  the  sinuses,  from  which  they 
invade,  and  compress  the  pulp  with  complete  atrophy  of  lym- 
phoid tissue.  From  this  point  the  cells  may  invade  the  capsule 
and  the  peripheral  lymphatics,  blood  vessels,  fat,  or  fibrous 
tissue. 

"When  the  metastatic  period  is  established  lymph-node  in- 
vasion may  follow  rapidly.  In  a  case  of  cancer  of  the  breast, 
a  swollen  axillary  node  examined  in  March  showed  only  inflam- 
matory hyperplasia  with  no  demonstrable  tumor  in  the  breast, 
but  in  June  the  entire  breast  was  infiltrated  by  a  flat,  diffuse 
growth,  and  some  axillary  nodes  were  completely  replaced  by 
cancer.  Since  many  tumor  metastases  long  remain  confined  to 
the  regional  lymph-nodes  and  fail  to  make  any  headway  through 
the  blood  stream,  it  may  be  assumed  that  there  is  a  regional 
and  general  immunity  against  implantation.  Yet  in  not  a  few 
cases  cancer  skips  the  regional  nodes  and  yields  distant  metas- 
tases. According  to  Gross  this  occurred  in  1  out  of  7  cases  of 
breast  cancer.  With  some  rapidly  growing  tumors  both  local 
and  general  susceptibility  to  metastases  exist  at  a  very  early 
period,  and  in  most  cases  one  must  conclude  that  the  growth 
capacities  of  the  cells  are  of  chief  importance  in  determining  the 
fate  of  cell  emboli. 

"In  not  a  few  cases  of  advanced  cancer  the  thoracic  duct  is 
invaded,  an  event  which  commonly  leads  to  wide  dissemination 
by  lymph-  and  blood-stream.  One  of  the  striking  results  of 
invasion  of  the  thoracic  duct  is  the  appearance  of  enlarged 
nodes  in  the  supraclavicular  region. 

"The  large  serous  cavities  are  penetrated  by  many  pathways, 
and  in  the  course  of  a  considerable  number  of  tumors,  chiefly 
those  of  contained  organs.  The  most  frequent  source  of  free 
peritoneal  growths  is  the  ovarian  adeno-carcinoma,  which  at 
any  period  may  rupture  its  covering  and  be  disseminated 
throughout  the  cavity.  Its  cells  rapidly  become  implanted  in 
the  peritoneum,  producing  miliary  or  large,  solid,  papillary, 
or  cystic  tumors,  with  a  tendency  to  ascites.  One  of  the  most 
remarkable  forms  of  peritoneal  cancer  arises  from  small  adeno- 


120  CANCER 

carcinomas  of  colon  or  appendix,  which  early  penetrate  the 
peritoneum,  spread  rapidly  throughout  the  greater  sac  and, 
retaining  the  large  alveolar  structure,  produce  enormous  quanti- 
ties of  mucus,  greatly  distending  the  abdomen.  I  have  seen 
gelatinous  cancer  of  the  rectum,  following  an  extra-peritoneal 
route,  fill  the  pelvis,  enclosing  rectum  and  bladder,  pass  up  the 
abdominal  parietes  in  front  and  retroperitoneal  tissues  behind, 
separating  liver  from  diaphragm,  inclosing  the  entire  abdomi- 
nal cavity  in  a  rigid  shell  3-5  cm.  in  thickness,  and  eventually 
invading  the  mesentery  and  subserous  intestinal  lymphatics, 
but  without  any  trace  of  intra-peritoneal  growth. 

"Peritoneal  invasion  is  a  very  common  complication  in  breast 
cancer,  and  occurs  as  Handley  shows,  often  by  the  way  of 
epigastric  lymphatics.  From  the  superficial  lymphatics  and 
along  the  falciform  and  round  ligaments  of  the  liver  he  has 
found  cancer  nodules  opening  into  the  peritoneum.  Loose 
cells  often  become  implanted  first  in  Douglas  sac  or  on  the 
ovary.  More  frequently  there  is  a  wide  spread  permeation  of 
the  subperitoneal  lymphatics,  which  may  become  almost 
universal.  It  is  associated  with  active  growth  of  hard  fibrous 
tissue,  producing  nodules  and  adhesions.  Eventually  the  entire 
peritoneum  becomes  thickened,  leathery,  and  opaque,  and  the 
omentum  shrinks  to  a  firm,  globular,  infiltrated  mass. 

"The  peritoneum  seems  to  have  very  little  capacity  to 
destroy  cancer  cells,  so  that  invasion  once  accomplished  is 
usually  progressive.  Gravity  and  the  muscular  contraction 
of  stomach,  intestines,  diaphragm,  and  parietes  assure  a  general 
dissemination  of  cells.  These  movements  may  cause  the 
separation  of  tumor  masses  which  have  been  found  free  in 
the  peritoneal  and  pleural  cavities,  while  the  aspirated  fluid 
nearly  always  contains  exfoliated  cancer-cells. 

"Intrapleural  and  intrapericardial  cancerous  invasion  occur 
chiefly  by  direct  invasion  from  cancer  of  the  breast,  bronchi, 
and  lung,  with  results  very  similar  to  those  produced  by  breast 
cancer  in  the  peritoneum." 

Ewing  and  others  state  that  the  removal  of  tumors  which 


METASTASIS  OF  CANCER  1 2 1 

have  been  shown  to  be  benign  by  the  microscope  is  occasionally 
followed  by  the  appearance  of  malignant  disease,  either  in 
situ  or  by  metastasis. 

There  is  still  something  to  be  said  which  has  not  been  covered 
by  the  above.  In  rare  cases,  with  and  without  treatment,  the 
primary  tumor  may  not  be  followed  by  metastases,  or  these 
may  be  of  very  late  development;  in  case  of  extirpation  there 
may  be  no  recurrence.  Nay  even  partial  removals  and  palli- 
ative operations  have  occasionally  seemed  to  cure  cancers 
which  have  been  termed  inoperable.  The  rationale  of  these 
cases  is  not  in  the  least  understood.  In  some  recorded  instances 
of  this  kind  in  literature  there  is  no  record  of  a  microscopic 
examination.  This  so-called  benign  or  semi-malignant  behavior 
of  cancer  may  at  times  be  explained  by  the  histology,  for  in 
cancer  of  the  breast  some  forms  are  known  to  be  less  malignant 
than  others. 

We  have  not  yet  mentioned  spontaneous  regression  of  cancer. 
A  small  number  of  cases  are  on  record,  but  they  teach  us 
nothing.  We  find  the  statement  that  regression  is  seldom 
complete,  some  of  the  neoplasm  remaining  behind,  but  we  do 
not  know  whether  this  statement  refers  to  so-called  cured 
cancers,  or  to  the  spontaneous  regressions  just  mentioned. 
The  dozen  or  more  of  the  latter  on  record  were  no  doubt  com- 
plete regressions.  The  fact  of  regression  must  not  be  welcomed 
too  gladly,  for  this  does  not  exclude  the  possibility  that 
metastasis  has  already  occurred. 

Much  could  also  be  said  regarding  local  recurrence.  After 
removal  of  a  growth  that  is  clearly  benign  in  all  respects,  there 
may  be  a  malignant  recurrence  in  situ.  After  removal  of  a 
primary  nodule  of  cancer  there  may  be  a  recurrence  close  by, 
due  evidently  to  an  outstanding  focus.  These  secondary 
nodules  not  infrequently  spring  up  in  the  neighborhood  of 
a  primary  focus.  It  is  evident  that  in  some  of  the  cases  the 
satellite  foci  can  remain  latent  over  long  periods,  until  roused  to 
activity  by  some  unknown  cause. 

In  regard  to  metastases,  appearance  of  the  disease  in  the 


122  CANCER 

regional  lymph-nodes  is  the  rule,  and  only  now  and  then  do  we 
see  cases  without  this  association.  It  may  be  early  or  late  in 
development.  Lymph-node  metastases  must  not  be  con- 
founded with  so-called  symphathetic  or  irritative  enlargement. 
This  latter  condition  tends  to  disappear  as  soon  as  the  primary 
growth  is  removed,  while  true  cancerous  metastasis  continues 
to  grow.  It  happens  now  and  then,  however,  that  cancerous 
lymph-nodes  disappear  after  removal  of  the  primary  growth. 
Biopsy  is  made  by  some  operators  to  distinguish  between  true 
and  pseudo-metastases.  The  prevalent  tendency,  however,  is 
to  extirpate  all  the  accessible  glands,  whether  normal  or  other- 
wise. In  certain  cases,  as  in  cancer  of  the  tonsil,  the  regional 
lymph-nodes  suppurate  as  a  result  of  infection;  so  that  cancer 
metastasis  and  septic  phlegmon  are  associated  in  the  same  sub- 
ject. In  cancer  of  the  nasal  fossae  metastases  are  as  a  rule  not 
in  evidence,  and  appear  in  positive  cases  very  late.  At  autopsy 
there  are  sometimes  found  metastases  in  the  nodes  which  are 
hidden  from  view,  by  their  deep  seat,  but  these  are  seldom 
serious. 

Lymph-node  metastases  are  almost  inevitable,  because  as  soon 
as  cancer  cells  break  through  the  basement  membrane  of  gland- 
ular structures  and  the  corresponding  limiting  connective  tissue 
in  other  situations,  they  enter  directly  into  the  lymph  channels, 
passing  from  these  into  the  nodes.  They  continue  to  infect  the 
secondary  nodes  and  those  beyond,  sometimes  skipping  one 
set  of  nodes;  and  in  such  cases  as  a  rule  only  one-half  of  the  body 
is  affected.  If  the  cancer  cells  enter  the  thoracic  duct  they  read- 
ily reach  the  blood,  but  in  most  cases  blood  metastases  are  due 
to  direct  entry  into  the  veins  of  the  tumor.  It  sometimes  hap- 
pens that  glandular  enlargements  occur  in  a  region  prone  to 
metastases  which  are  not  directly  induced  by  cancer,  but  are 
exposed  to  forms  of  malignancy  peculiar  to  themselves.  Thus 
it  may  be  difficult  at  times  to  distinguish  between  malignant 
lymph-adenoma  of  the  neck,  which  is  a  primary  manifestation, 
and  secondary  lymph-node  metastases  due  to  cancer  somewhere 
in  the  buccal  or  neighboring  cavities. 


METASTASIS  OF  CANCER  1 23 

Blood  metastases  do  occur  in  cancer,  but  many  cases  which 
at  first  sight  seem  to  be  due  to  blood  transmission,  are  found  at 
autopsy  to  have  been  examples  of  transmission  along  lymph 
vessels.  These  blood  metastases  are  seen  as  a  rule  in  sarcoma 
and  in  certain  locations  of  carcinoma.  Among  the  latter  are 
primary  cancer  of  the  liver  and  kidneys  and  the  prostate. 
Lymph  metastases  tend  to  occur  in  cancer  of  the  skin  and  mucosae, 
where  regional  lymph-nodes  are  present.  In  cancerous  pro- 
pagation along  the  lymphatics  the  cancer  cells  are  able  to  make 
headway  against  the  lymph  stream,  and  cause  so-called  retro- 
grade metastases.  Cancer  cells  may  circulate  in  the  blood  of  an 
individual  without  causing  metastases;  and  at  the  other  extreme 
metastasis  may  result  in  benign  growths,  as  chondroma  of  the 
testes.  Indeed  normal  tissue,  as  in  ordinary  thyroid  adenoma, 
may  metastasize  extensively  into  the  bones  and  cause  lesions 
which  while  not  technically  malignant,  require,  when  possible, 
surgical  removal. 

The  general  rule  is  that  metastases  are  more  malignant  than 
the  primary  focus,  although  there  are  exceptions.  If  a  primary 
growth  makes  but  little  stroma,  a  bone  metastasis  may  never- 
theless contain  much  new  bone  tissue.  Metastases  almost  al- 
ways follow  the  type  of  the  parent  growth,  but  there  may  be  a 
falling  off  in  anaplasia,  as  when  metastases  of  epidermal  cancer 
are  found  to  contain  no  pearls.  In  distinction  to  cancer,  malig- 
nant teratomata  cause  metastases  which  are  unlike  the  parent 
growth — those  of  chorioepithelioma.  Bone  metastases  have 
also  appeared  at  a  very  late  day — thus,  when  there  has  been 
no  local  recurrence  after  5  years  in  breast  tumors,  metastases 
have  yet  appeared  in  some  of  the  long  bones. 

It  is  very  easy  for  the  surgeon  to  contribute  to  the  production 
of  metastases.  In  the  course  of  operation  he  may  cause  inocu- 
lation or  transplantation  metastasis.  Both  biopsies  and  rough 
handling  in  examination  and  operation,  as  well  as  the  mere  use 
of  the  knife  in  laying  open  blood  vessels,  invite  metastases.  It 
is  also  claimed  that  one  can  also  ward  off  some  of  the  dangers  of 
metastasis  by  graying  all  the  lymphatics.     This  is  said  to  cause 


124  CANCER 

a  narrowing  of  the  latter,  and  it  is  known  that  the  narrower  the 
vessel  the  more  difficult  is  it  for  cancer  cells  to  pass.  A  factor 
in  metastasis  is  the  character  of  the  tissue  for  furnishing  nutri- 
ment in  which  the  cancer  cells  are  arrested.  The  cancer  cell 
requires  a  special  type  of  nutriment,  and  when  a  metastasis  fails 
to  take  place  it  is  alleged  to  be  due  to  this  cause.  Most  metas- 
tases in  the  general  blood  circulation  involve  the  lungs  because 
of  the  relative  narrowness  of  the  capillaries;  but  some  of  them 
may  pass  and  enter  the  liver  and  other  viscera.  Cancer  in  the 
portal  area  always  metastasizes  in  the  liver.  Certain  organs 
are  quite  immune  to  metastases,  for  the  cancer  cells  in  these 
regions  cause  only  emboli.  Here  belong  the  pancreas,  thyroid, 
cardiac  wall,  and  muscles.  Metastases  and  cachexia  are  usu- 
ally associated,  but  either  may  occur  without  the  others. 

The  study  of  the  progress  of  neo-plastic  growths  by  metas- 
tasis is  thus  seen  to  be  a  most  interesting  one,  which  throws 
much  light  upon  the  resistance  of  cancer  to  surgical  measures: 
which  many  are  beginning  to  recognize  more  and  more  clearly. 
The  part  played  by  the  lymphatic  system  both  in  the  nourish- 
ment and  metabolism  of  the  body  is  an  enormous  one  which 
will  be  further  studied  in  a  later  chapter,  but  which  must  be 
briefly  considered  here  in  order  to  understand  the  relation  of 
what  has  preceded  to  cancer. 

All  are  familiar  with  the  lacteals  of  the  stomach  and  intes- 
tines, and  the  important  part  they  play  in  carrying  the  products 
of  digestion  into  the  system  through  the  thoracic  duct.  Less 
thought,  however,  is  given  to  the  immense  importance  of  the 
lymphatic  system  in  removing  from  the  tissues  the  results  of 
catabolism,  or  the  disintegration  of  effete  body  elements,  and 
passing  them  again  into  the  general  circulation  through  the 
thoracic  duct,  for  the  action  upon  them  of  the  various  organs 
of  the  body.  From  observation  upon  a  case  with  a  lymph 
fistula  it  has  been  estimated  that  in  man  the  flow  of  lymph 
may  be  equal  to  from  50  to  100  or  120  c.c.  per  hour.  The 
lymph  glands  through  their  lymph  cells,  act  as  the  first  modifier 


METASTASIS   OF   CANCER  125 

of  this  stream,  before  it  passes  through  the  lungs,  mingled  with 
venous  blood,  for  oxidation,  arresting  foreign  elements,  such 
as  micro-organisms,  as  we  see  in  many  diseases. 

One  can  readily  understand,  therefore,  how  a  disturbance  in 
this  great  circulating  system,  by  disturbing  or  abrogating  the 
action  of  its  digestive  nodes,  as  well  as  by  blocking  its  circu- 
lation by  the  inroads  of  carcinomatous  cells,  can  very  seriously 
affect  the  nutrition  of  the  body.  Also  it  is  evident  that  the 
great  multiplication  of  carcinomatous  centres,  each  giving 
off  its  poisonous  hormone,  to  be  further  considered  in  a  later 
chapter,  induces  the  cachexia  of  carcinosis,  by  further  deteriora- 
ting the  blood,  as  will  also  be  discussed  later.  It  is  seen, 
therefore,  that  the  mere  removal  of  the  primary  lesion  or 
lump,  which  we  call  cancer,  by  surgery,  #-ray,  or  radium,  is 
a  small  factor  in  the  cure  of  the  disease,  if  the  lymphatics  or 
distant  tissues  have  been  invaded.  It  will  be  shown  later  how 
even  less  reasonable  it  is  to  expect  a  real  cure  of  the  disease  if 
the  constitutional  disturbances  still  continue  which  produced 
the  original  tumor,  and  which  will  pretty  certainly  produce 
others. 


CHAPTER  IX 
MALIGNANCY  OF  CANCER 

In  the  preceding  chapter  we  have  seen  how  seriously  cancer 
interferes  with  the  action  of  that  most  important  circulatory 
system,  the  lymphatic,  upon  which  so  much  of  the  nutritive 
and  metabolic  action  of  the  cells  depends.  Lymph  stasis  is 
recognized  as  an  important  feature  in  many  other  diseased 
conditions,  and  disordered  action  of  the  protective  and  blood 
making  function  of  the  lymphatic  glands  naturally  leads  to 
faulty  metabolism,  and  to  an  incorrect  blood  current.  For 
we  must  remember  that  malignancy  is  physiologic  and  not 
anatomic.  We  will  note  later  the  changes  in  the  blood  and 
secretions  taking  place  both  in  early  and  late  cancer.  Malig- 
nancy is  also  furthered  by  the  derangement  produced  by 
metastasis  in  the  various  organs,  including  those  concerned  in 
nutrition  and  blood  making,  and,  finally,  by  the  general  toxic 
action  of  absorbed  tumor  products,  which  is  recognized  as  an 
important  factor  in  malignancy. 

Ewing  says:  "The  general  intoxication  resulting  from  tumor 
growth  is  a  complex  subject  which  has  long  been  recognized 
as  one  of  the  most  obscure  and  important  problems  in  the 
natural  history  of  malignant  tumors.  Hemorrhage,  mechanical 
interference  with  nutrition,  pain,  the  psychical  condition, 
abnormal  secretion,  destruction  of  important  tissues,  the  toxic 
action  of  products  absorbed  from  degenerating  and  ulcerating 
areas,  and  bacterial  infection  combine  to  produce  the  cachexia 
of  tumors.  When  the  clinical  signs  of  malignancy  declare 
themselves,  the  conditions  exciting  them  often  belong  to  the 
past  history  of  the  disease  and  are  often  irremediable. 

"The  prediction  of  the  course  that  a  given  tumor  will  take 
is  based  upon  two  sources  of  information:  i.  Anatomical  and 
microscopical  diagnosis,  and  2.  Accumulated  experience  regard- 

126 


MALIGNANCY  OF   CANCER  127 

ing  the  usual  behavior  of  tumor  of  known  histological  structure. 
Fortunately,  a  parallel  exists  to  a  very  marked  degree  between 
the  histological  structures  and  the  usual  clinical  course."  But 
he  quite  insists  that  the  correct  interpretation  of  structure  in 
the  light  of  clinical  data  requires  a  very  wide  experience,  not 
only  with  the  general  tendencies  of  specific  structures,  but  with 
the  observed  courses  of  different  tumors,  as  many  will  also 
agree  who  have  had  experience  with  different,  or  rather 
indifferent,  microscopists. 

"A  somewhat  general  estimate  of  the  malignancy  of  tumors 
may  be  based  on  the  distinctions  between  adult  and  embryonal 
or  anaplastic  growth.  It  has  long  been  recognized  that  the 
greater  variation  in  type  between  a  tumor  and  its  originating 
tissue,  the  more  malignant  the  tumor,  and  Hanseman  has 
effectually  emphasized  this  principle,  pointing  out  that  the 
morphological  evidences  of  anaplastia  have  a  physiological 
significance,  indicating  the  degree  to  which  the  process  is  freed 
from  growth  restraints  and  from  the  control  of  the  organism. 
Yet  here  is  encountered  the  difficulty,  of  distinguishing  between 
original  embryonal  qualities  and  signs  of  acquired  anaplasia. 
One  group  of  tumors  arises  from  embryonal  cells  which  have 
lagged  behind  in  development,  and  such  tumors  bear  an 
embryonal  stamp.  The  histological  signs  of  this  embryonal 
character  are  often  difficult  to  distinguish  from  the  signs  of 
anaplasia,  and  if  they  are  wrongly  interpreted  an  erroneous 
impression  may  be  drawn  of  the  malignancy  of  the  tumor. 
The  great  theoretical  value  of  the  distinction  between  embry- 
onal and  anaplastic  cells  is  not,  however,  equal  in  practical 
importance,  since  both  types  of  tumors,  especially  the  latter, 
are  usually  quite  malignant.  The  histological  signs  of  anapla- 
sia are,  a  cellular  character,  marked  variations  in  size  in  either 
direction  from  the  originating  cells,  increase  of  chromatic, 
nuclear  substance,  abundance  and  abnormality  of  mitoses, 
and  a  loss  of  polarity,  and  diffuse  infiltrative  growth  of  cells. 
In  many  instances  lack  of  reaction  of  the  tissues  against  the 
infiltration   of   tumor-cells  is  a   significant  feature.     Equally 


128  CANCER 

important  are  the  general  signs  of  exalted  nutrition  and  vitality 
of  the  cells.  Upon  these  features  one  may  safely  base  the 
estimate  of  growth  capacity  and  potential  malignancy  of 
tumors." 

"The  histological  signs  of  malignancy  measure  the  potential 
malignancy  of  a  tumor,  but  the  clinical  course  is  subject  to 
wide  variations  from  the  position  of  the  tumor,  hemorrhage, 
trauma,  changes  in  rate  of  growth,  bacterial  infection,  etc., 
any  one  of  which  influences  may  greatly  alter  the  course. 
With  these  important  limitations  it  may  be  asserted  that  there 
is  a  close  parallel  between  histological  structure  and  the 
malignancy  of  a  tumor. 

"The  emaciation  accompanying  tumor  growths  has  long  been 
recognized  as  one  of  the  most  significant  and  obscure  of  its 
many  features.  It  may  be  said  to  be  a  constant  effect  of  both 
very  malignant  and  relatively  benign  tumors.  It  occurs  early 
or  late,  with  or  without  anaemia,  though  probably  always 
with  diminution  in  the  total  volume  of  blood,  sometimes 
with  preservation  of  the  fat  deposits,  and  is  preceded  by  distinct 
muscular  weakness.  It  affects  chiefly  the  muscular  system, 
but  also  all  cellular  organs  and  tissues.  Inanition  is  undoubt- 
edly the  chief  factor  in  the  loss  of  weight.  Mental  depression, 
leading  to  distaste  of  food,  the  lowering  of  the  digestive  capa- 
city, and  mechanical  obstructions  to  the  alimentary  passages, 
reduce  the  amount  of  food  absorbed.  In  six  cases  of  uterine 
cancer  V.  Norden  calculated  the  voluntary  ingesta  at  300  to 
1,200  calories. 

11  The  Blood  in  Cancer. — The  great  majority  of  malignant 
tumors  are  associated  throughout  most  of  their  course  with  pro- 
gressive deterioration  in  the  quality  and  quantity  of  the  blood. 
Usually  the  anemia  takes  the  form  of  a  secondary  chlorotic 
process,  with  loss  of  hemoglobin  exceeding  the  reduction  of 
cells,  low  hemoglobin  index,  and  slight  leucocytosis.  In  a 
notable  group  of  cancers  of  the  stomach  the  anemia  dominates 
the  clinical  picture,  and  takes  a  secondary,  pernicious  form. 

"The  absorption  of  hemolytic  agents  from  ulcerated  and 


MALIGNANCY  OF  CANCER  129 

infected  surfaces,  and  from  necrosing  areas  of  closed  tumors,  is 
a  chief  factor  in  producing  anemia.  Maragliano,  Kullman, 
Bard,  Polk  and  many  others  have  demonstrated  the  presence 
of  hemolytic  properties  in  the  blood  of  cancer.  Elsberg  found 
that  normal  red  cells  injected  beneath  the  skin  of  cancerous 
subjects  were  soon  hemolyzed,  yielding  a  characteristic  dis- 
coloration of  the  skin,  and  he  proposed  this  method  as  a 
diagnostic  test  for  carcinoma.  In  extracts  of  degenerating  and 
necrosing  tumors  Weil  demonstrated  thermolabile  and  thermo- 
stabile  hemolysins,  not  differing  from  those  obtained  from 
necrosing  normal  organs.  Clinical  effects  of  such  hemolysins 
were  observed  by  Bard,  who  pointed  out  that  in  cancerous 
pleuritic  exudates  the  red  cells  are  often  hemolyzed,  while  in 
other  bloody  pleural  fluids  the  red  cells  are  intact. 

"The  specific  gravity  of  the  blood  in  most  cases  does  not 
differ  from  that  of  the  other  forms  of  secondary  anaemia,  but 
in  well-established  cachexia  the  specific  gravity  has  often  been 
found  remarkably  low.  The  albumins  of  both  plasma  and 
serum  are  distinctly  low  in  such  cases  (Gravitz).  In  a  case  of 
gastric  cancer  Wendelstadt  and  Bleibtreu  found  0.70  gm., 
instead  of  the  normal  2  to  2.25  gms.,  in  100  gms.  blood-serum. 

" Leucocytosis  was  early  recognized  as  a  very  frequent  condi- 
tion in  cancer,  having  been  described  post-mortem  by  Andral 
in  1823,  and  in  the  circulating  blood  by  Lucke  and  Virchow 
about  1867  .  .  .Ulceration  or  other  inflammatory  complica- 
tions are  the  most  definite  causes  of  leucocytosis  in  cancer, 
and  the  resulting  hemorrhage  adds  to  the  increase  of  white 
cells  seen  in  bleeding  and  necrosing  tumors.  Bacterial  infec- 
tion, local  and  general,  may  intensify  the  effects  of  absorption 
of  tissue  toxins  and  loss  of  blood. 

"  The  total  quantity  of  Blood  in  cases  of  malignant  tumor  varies 
greatly,  but  as  Louis  showed  in  1846,  it  is  usually  much  dimin- 
ished. The  regeneration  of  the  blood  in  cancer  has  been  found  by 
Bierfreund  to  require  much  longer  time  than  in  other  surgical 
conditions,  and  in  progressive  cases  the  hemoglobin  seldom 
reaches  the  ratio  existing  before  operation. 


130  CANCER 

"Alkalescence  of  the  Blood.— Determination  of  the  alkale- 
scence of  the  blood  have  yielded  results  which  differ  with  the 
methods  employed  and  the  particular  factors  brought  into 
consideration.  Klemperer  found  a  reduced  amount  of  carbonic 
acid  in  the  blood  in  advanced  cancer.  Peiper  tritrating  the 
whole  blood,  found  very  low  grades  of  alkalescence  in  advanced 
cachexia,  and  Rumpf,  Limbeck,  and  others,  dealing  with  the 
whole  blood,  obtained  uniform  diminution  of  alkali  in  advanced 
cases. 

"Influence  of  Cancer  on  Digestion. — The  absence  of  free 
hydrochloric  acid  in  the  gastric  contents  of  cancer  of  the 
stomach,  discovered  by  Van  der  Velden  in  1879,  and  thoroughly 
investigated  by  many  later  writers,  stands  as  a  prime  factor  in 
the  anemia  and  mal-nutrition  of  this  disease.  In  all  but  from 
10  to  13  per  cent  of  such  cases  free  hydrochloric  acid  is  missing 
(Richter).  When  cancer  is  grafted  on  simple  ulcer  the  early 
stages  of  the  process  may  be  marked  by  the  excess  of  free  hydro- 
chloric acid  belonging  to  the  former  condition,  but  as  a  rule, 
this  excess  declines  and  eventually  disappears,  sometimes 
suddenly,  as  the  disease  progresses  (Rosenheim,  Schneider) .  In 
most  cases  the  loss  occurs  early  in  the  disease  (Riegel) ...  In 
other  cancers,  not  involving  the  stomach,  a  simlar  deficiency  of 
hydrochloric  acid  occurs,  so  that  it  seems  necessary  to  assume 
that  malignant  disease  exerts  some  general  influence  which 
affects  gastric  secretion,  even  in  the  absence  of  severe  anemia 
and    cachexia. 

"As  a  result  of  diminished  digestive  capacity,  disturbances  of 
motility,  and  retarded  absorption,  abnormal  fermentative 
processes  become  established,  and  various  bacterial  species 
find  a  favorable  soil.  The  products  of  fermentation  include 
lactic,  butyric,  and  acetic  acids,  alcohol,  and  protein  decomposi- 
tion products.  Boas  at  one  time  claimed  that  the  presence  of 
lactic  acid  in  the  stomach  contents  was  specific  of  carcinoma, 
and  appeared  at  an  early  stage,  when  stagnation  and  loss  of 
free  hydrochloric  acid  did  not  exist,  but  it  has  since  been  shown 
that  the  presence  of  lactic  acid  is  dependent  upon  impaired 


MALIGNANCY  OF  CANCER  131 

motility  and  deficiency  of  hydrochloric  acid  (Strauss,  Wagner, 
Seelig).  Since  these  conditions  are  present  in  very  early  cancer, 
and  since,  as  Sick  has  shown,  formation  of  lactic  acid  is  favored 
by  decomposition  products  of  cancer  tissue,  the  test  for  lactic 
acid  is  of  considerable  diagnostic  value. 

11  Intestinal  digestion  suffers  in  many  ways  from  malignant 
tumors  of  the  gastrio-intestinal  tract  and  its  accessory  glands. 
With  gastric  cancer  the  discharge  of  abnormal  digestive  putre- 
factive and  bacterial  products  into  the  intestine  tends  to  incite 
disorder  throughout  the  entire  course  of  digestion,  and  Wasbut- 
ski,  Kast,  and  others  have  shown  that  intestinal  decomposition 
occurs,  especially  with  loss  of  free  hydrochloric  acid  and  active 
fermentation  in  the  stomach.  The  main  effects  of  tumors  of 
the  intestinal  tract  are  the  result  of  stenosis  and  ulceration,  and 
either  of  these  conditions  in  pronounced  form  has  a  prompt 
influence  on  general  nutrition.  Excessive  indicanuria  tells  of 
absorption  of  putrefactive  products  in  stenosis,  and  formation  of 
fistulous  tracts  may  complicate  and  terminate  the  course,  with- 
out much  influence  on  the  extent  of  this  absorption. 

" Blood  in  the  Stools  offers  a  means  of  diagnosis  in  ulcerating 
tumors,  and  constitutes  a  serious  source  of  anaemia.  Acholic 
stools  results  from  cancerous  stenosis  of  the  common  duct,  and 
impaired  digestion  of  fats  follows  destruction  of  the  pancreas 
and  obstruction  of  its  duct.  Tumors  of  the  liver,  bile  passages, 
pancreas,  cecum,  and  rectum  produce  various  important  clini- 
cal types  of  disease.  Here  it  may  only  be  said  that  all  of  these 
conditions  tend  to  produce  cachexia  through  the  combination 
of  very  numerous  factors,  which  must  be  analyzed  for  each  case, 
and  the  variety  of  which  reveals  the  very  complex  nature  of 
tumor  cachexia. 

"Changes  in  the  Urine. — Specific  alterations  in  the  urine  have 
not  been  demonstrated,  but  its  composition  varies  according  to 
general  rules.  Uric  acid  may  be  increased  without  relation  to  leu- 
cocytosis.  Ammonia  nitrogen  has  not  been  found  to  show  any 
variations  other  than  those  dependent  upon  digestion  and  nutri- 
tion.  Herter  found  high  ammonia  in  the  coma  of  gastric  cancer. 


132  CANCER 

"Rest  nitrogen,  chiefly  amino-acids,  is  higher  than  in  some 
abnormal  states,  and  increases  with  the  progress  of  the  disease 
(Setti).  Salkowski  has  drawn  attention  to  an  increase  in  the 
colloidal  nitrogen  precipitable  by  alcohol,  in  cancer.  This  frac- 
tion corresponds  partly  to  the  amino-acids  (Wolff).  Later 
Salkowski  estimated  the  nitrogen  precipitated  by  lead-acetate, 
after  the  removal  of  phosphates  by  alkaline  barium  chloride, 
finding  that  this  nitrogen  fraction  is  greatly  increased  in  cancer. 
The  nitrogen  estimated  by  Salkowski  probably  includes  the 
oxyproteic  acids  and  polypeptids. 

"  An  increase  of  unoxidized  sulphur  has  also  been  observed  by 
M.  Weiss  and  others,  and  Salomon  and  Saxl  have  demonstrated 
such  a  notable  and  uniform  increase  in  oxidizable  neutral  sul- 
phur as  to  indicate  its  value  in  diagnosis.  Lehman  points  out 
that  the  results  of  this  test  depend  largely  on  the  diet,  without 
the  control  of  which  the  examination  is  useless.  From  observa- 
tions in  this  field  Saxl  concludes  that  various  analytic  methods 
demonstrate  the  occurrence  in  notably  increased  amounts  of 
protein  derivatives,  chiefly  oxyproteic  acids,  which  escape  the 
normal  transformation  into  urea.  In  general  he  finds  a  some- 
what specific  disturbance  of  metabolism  in  cancer,  marked  by  a 
nearly  constant  excess  in  total  metabolism,  relative  reduction 
in  urea  formation,  increased  ammonia  excretion  and  increase  of 
protein  derivatives  which  fail  of  oxidation  into  urea.  In  no 
other  disease,  except  certain  special  intoxications,  is  the  internal 
oxidation  of  protein  so  much  disturbed  as  in  cancer.  Saxl  goes 
on  to  show  that  the  disturbance  of  oxidation  is  probably  due  to 
accumulation  in  the  system  of  rhodan,  an  oxidation  product  of 
hydrocyanic  acid,  since  this  substance  is  increased  in  the  urine 
in  cancer,  and  when  administered  to  man  reproduces  the  typical 
metabolic  disturbances  of  cancer.  The  basis  of  this  theory 
remains  to  be  verified. 

"Products  of  putrefaction  are  found  in  increased  quantities 
in  the  urine  of  advanced  cancer,  but  the  exact  source  of  the 
substances  has  not  been  fully  determined.  Indican,  phenol, 
aromatic  oxyacids,  and  ethereal  sulphates  have  been  estimated 


MALIGNANCY  OF  CANCER  133 

by  several  observers,  who  attribute  their  presence  to  intestinal 
putrefaction,  to  decomposition  of  secretions,  and  to  destruction 
of  tumor  tissue.  That  intestinal  putrefaction  is  not  the  sole 
source  is  indicated  by  the  considerable  quantities  of  such  sub- 
stances observed  with  decomposing  tumors  of  the  breast  and 
uterus  (Brieger,  Haberlin,  Hennige).  Leviwn  finds  excess  of 
aromatic  acids  in  patients  with  nitrogen  loss,  but  not  with  those 
showing  nitrogen  retention,  and  concludes  that  these  substances 
are  derived  from  the  toxic  destruction  of  tumor  and  tissue  pro- 
teins, and  not  wholly  from  intestinal  putrefaction. 

"  Acidosis  of  Cancer. — The  acetone  bodies  in  cancer  follow  the 
same  rules  as  in  other  conditions.  Their  presence  in  the  urine 
bears  no  relation  to  the  growth  of  cancer  as  such,  and  their  sub- 
stances are  absent  in  the  early  stages  of  the  disease,  and  when 
the  patient  is  well  fed  (Waldvogel).  With  the  advent  of  protein 
loss  and  cachexia,  acetone  and  diacetic  acid  commonly  appear  in 
the  urine,  and  beta-oxybutyric  acid  is  added  in  severe  inanition. 
It  is  not  entirely  clear  that  cancer  coma  is  purely  an  acid  intoxi- 
cation, and  it  seems  probable  that  the  rapid  burning  of  tissue 
fats  and  proteins,  of  which  acidosis  is  only  one  result, 
may  be  responsible  for  some  of  the  sudden  terminations  of 
malignant  tumors.  Von  Noorden's  observation  of  consider- 
able quantities  of  lactic  acid  in  the  urine  of  two  cases  suggests 
that  the  acidosis  of  cancer  may  involve  hepatic  disturbance  as 
well  as  pure  acidemia. 

"Albuminuria  occurs  in  most  cases  of  cancerous  cachexia, 
but  is  absent  in  early  stages  of  the  disease.  According  to  Mul- 
ler  it  occurs  in  35  to  72  per  cent  of  all  cases  of  carcinoma.  In 
cancer  of  the  alimentary  tract  albumoses  are  very  often  present 
(Ury,  Lilienthal),  either  by  direct  absorption  of  digestive  pro- 
ducts through  the  ulcerated  surface  (Maixner)  or  from  the  dis- 
integration of  tumor  tissues  (Pacanowski) . " 

Cancer  Cachexia. — The  statement  by  Woglom  in  the  article 
"Neoplasms"  in  Wood's  Handbook,  which  throws  doubt  on  the 
existence  of  special  malignant  tumor  cachexia  is  a  good 
example  of  how  authorities  constantly  overlook  certain  points 


134  CANCER 

when  generalizing  on  malignancy.  A  tumor  with  its  primary 
manifestation  and  often  large  lymph  or  blood  metastases,  etc., 
requires  nourishment  and  will  go  to  any  length  to  take  it  from 
the  body  tissues.  This  shows  that  the  innate  impulse  to 
limitless  and  lawless  growth  is  quite  independent  of  a  rich 
blood  supply  or  excess  of  nutrition.  Cancer  anemia  is  de- 
veloped often  in  a  high  degree,  yet  the  growth  is  not  arrested; 
and  the  general  breakdown  of  the  organism  must  be  charged 
chiefly  to  the  absorption  of  much  or  most  of  the  nutrient 
material  by  the  growth  of  the  tumor.  Wood  in  his  article  on 
"Cancer"  in  "Wood's  Reference  Handbook  of  the  Medical  Sci- 
ences" states  that  cancer  cachexia  is  the  sum  of  all  the  injurious 
consequences  of  the  disease,  including  pallor,  emaciation,  loss 
of  appetite,  and  asthenia.  It  is  not  a  specific  manifestation, 
for  it  does  not  differ  from  the  cachexia  in  chronic  hemorrhagic 
affections  and  chronic  suppurations,  but  it  is  seen  more  fre- 
quently with  cancer  than  with  any  other  affection.  Of  two 
theories  one  is  that  the  tumor  takes  the  nutriment  intended 
for  the  body  while  the  other  holds  that  the  tumor  secretes 
a  toxic  sustance — not  per  se,  but  as  a  result  of  degenerative 
processes.  Cachexia  cannot  precede  cancer  although  this  was 
once  held  to  be  the  case.  It  is  most  significant  that  it  can 
disappear  when  the  growth  is  removed,  to  return  with  recur- 
rence of  the  growth.  It  cannot  be  due  to  sepsis,  although  the 
latter  can  coexist.  Wood  is  inclined  to  blame  it  on  a  special 
tendency  of  cancer  cells  to  undergo  degeneration  and  pre- 
sumably to  form  noxious  substances.  Cachexia  is  often  as- 
sociated in  appearance  wth  metastases,  the  latter  being  held 
to  undergo  rapid  degenerative  alterations.  A  large  breast 
tumor  may  not  show  any  cachectic  accompaniment. 

Anyone  who  carefully  considers  this  remarkable  study  of  the 
elements  of  malignancy  in  cancer,  abstracted  from  the  most  care- 
ful and  elaborate  analysis  of  the  matter  by  Dr.  Ewing,  a  pure 
scientist,  and  other  laboratory  workers,  must  be  struck  with 
the  constant  recurrence  of  references  to  metabolism,  nutrition, 


MALIGNANCY  OF  CANCER  135 

the  character  of  the  blood  and  the  action  of  the  various  organs 
concerned  in  the  operation  of  the  human  system,  etc.,  and 
wonders  why  there  should  be  any  doubt  in  regard  to  the  consti- 
tutional nature  of  cancer.  The  link  that  is  missing  in  the  evi- 
dence undoubtedly  relates  to  the  question  as  to  whether  the 
various  systemic  changes  observed  in  cancer  patients  are  a  cause 
or  an  effect  of  the  disease. 

The  unfortunate  part  of  all  such  laboratory  study  is,  that  it 
always  relates  largely,  or  almost  entirely,  to  conditions  found  in 
patients  where  the  malignant  process  has  been  going  on  for 
some  time,  and  there  has  been  so  little  minute  searching 
for  the  clinical  and  bio-chemical  conditions  existing  in  those 
with  very  early  cancer,  or  even  in  those  predisposed  to  it  by 
hereditary  influence.  Also  that  so  little  attention  has  been 
devoted  or  to  the  study  and  observation  of  those  inclined 
to  it  by  habits  of  life  or  surroundings,  which  have  been 
found  later  in  those  who  have  already  developed  the  disease: 
(for  instance,  obseity  is  recognized  as  being  of  great  importance 
in  connection  with  recurrences  of  cancer  of  the  breast),  as  also 
the  many  points  of  living,  which  are  brought  out  in  later 
chapters. 

Looking  at  the  question  from  a  common  sense  and  scientific 
standpoint,  it  is  recognized  that  there  must  be  a  cause  for  every- 
thing, and  that  the  gross  disturbances  of  the  system  associated 
with  cancer,  ending  fatally  if  unchecked,  must  have  a  definite 
cause,  although  thus  far  all  surgical  writers  affirm  that  no  cause 
is  known.  It  is  inconceivable  and  impossible  to  believe  that  the 
misbehaviour  of  a  cell,  or  a  small  group  of  cells,  in  any  of  the 
various  parts  of  the  body  can,  without  cause,  excite  a  malignant 
process  which  ultimately  becomes  so  destructive,  unless  the 
cause  which  first  induced  the  cell  misbehaviour  has  also  existed 
throughout  the  whole  course  of  the  trouble.  In  other  words, 
the  theory  of  a  purely  local  nature  of  the  disease  is  quite  unten- 
able. We  have  already  seen  that  a  parasitic  cause  is  rejected 
by  all  who  have  laboriously  studied  the  question,  etc.  True 
it  is  that  cancer  first  manifests  itself  in  one  particular  spot, 


136  CANCER 

remaining  there  and  increasing,  but  that  is  so  with  other 
diseases. 

As  will  be  seen  in  later  chapters,  there  are  so  many  features 
pointing  unmistakably  to  the  constitutional  character  of  cancer 
(endorsed  by  so  many  surgeons  and  physicians),  including  its 
control  by  dietary,  hygienic,  and  medicinal  measures,  that  it 
need  not  be  any  longer  declared  that  we  know  nothing  of  its  cause. 

There  are  still  unfortunately  many  other  affections,  such  as 
pernicious  anaemia  and  other  diseases  of  the  blood  (which 
remind  one  of  the  pathogenesis  of  cancer),  of  which  this  is  still 
said,  but,  as  in  the  case  of  tuberculosis  we  now  know  that 
restored  metabolism  and  corrected  nutrition  will  even  over- 
come the  harmful  influence  of  the  ever  present  tubercle  bacilli. 
So  in  the  case  of  cancer  much  the  same  measures,  along  some- 
what different  lines,  can  and  do  overcome  the  carcinosis  or 
cancerous  dyscrasia,  even  in  established  cases,  if  intelligently 
and  long  persisted  in. 


CHAPTER  X 
METABOLISM  OF  CANCER 

In  former  chapters  we  have  considered  the  histo-pathology, 
the  bio-chemistry,  metastasis,  and  malignancy  of  cancer,  and 
we  will  now  examine  the  data  in  regard  to  the  metabolism  of 
the  system  leading  up  to  these  conditions.  There  will  be 
necessarily  some  little  repetition  of  what  has  preceded,  in  order 
to  grasp  intelligently  the  basic  facts  of  the  true  pathogenesis 
of  the  disease. 

The  common  opinion,  and  statement,  is  that  nothing  is 
known  in  regard  to  the  cause  of  cancer.  Long  continued  and 
abundant  laboratory  and  clinical  research  have  about  decided 
certain  negative  questions  in  regard  to  the  disease,  so  that  in  a 
measure  the  field  is  cleared  for  the  study  of  some  of  its  possible 
basic  causes. 

Thus,  all  are  pretty  well  agreed  that,  i.  Cancer  is  not  con- 
tagious or  infectious:  2.  It  is  not  caused  by  a  micro-organism 
or  parasite:  3.  It  is  not  wholly  due  to  local  injury:  4.  It  does 
not  appertain  to  any  particular  occupation:  5.  It  is  not  heredi- 
tary to  any  great  degree:  6.  It  does  not  especially  belong  to  or 
affect  any  particular  sex,  race,  or  class  of  persons:  7.  It  is 
not  confined  to  any  location  or  section  of  the  earth:  8.  It  is 
not  wholly  a  disease  of  old  age.  By  exclusion,  therefore,  we  are 
left  to  conclude  that  it  develops  from  some  cause  pertaining 
to  the  individual,  to  the  manner  in  which  the  tissues  are  devel- 
oped, nutrified  and  changed,  and  these  we  know  are  effected  by 
certain  systemic  processes  to  which  has  been  given  the  name 
metabolism,  with  its  two  divisions,  catabolism  and  anaboiism. 

It  is  not  a  little  strange  that  the  efforts  of  the  various  agencies 
engaged  in  Cancer  Research  have  not  been  directed  to  this 
aspect  of  the  question,  and  to  a  clinical  and  other  study  of  the 

1.37 


138  CANCER 

effect  of  diet  and  mode  of  life  in  producing  cancer,  of  which 
evidence  appears  in  these  pages,  instead  of  so  much  microscopic 
study  of  tissues  and  animal  experimentation. 

W.  Roger  Williams1  in  1894,  wrote:  "Do  cancers,  and  other 
neoplasms,  arise,  as  John  Hunter  and  Johannes  Muller  main- 
tained, through  a  modification  of  a  formative  process:  or,  are 
they  the  outcome  of  the  inflammatory  process,  owing  to  the 
presence  of  micro-organisms,  or  some  other  sources  of  irrita- 
tion? In  other  words  are  they,  directly  or  indirectly,  due  to  the 
intrusion  of  some  irritant,  ab  extra?  I  incline  to  the  former 
alternative:  and  I  think  the  future  will  see  decided  reaction 
in  this  direction.  ...  In  the  genesis  of  neoplasms,  as  in  the 
genesis  of  other  organic  structures,  I  believe  that  we  must  take 
into  consideration  two  factors — the  cells  whence  they  originate, 
and  the.  force  that  regulates  cellular  activities." 

Of  late  years  considerable  attention  has  been  paid  to  the 
possible  influence  of  "embryonic  rests,"  or  pre-natal,  wrongly 
placed  tissue  elements,  in  the  causation  of  cancer,  and  Ewing2 
has  shown  that  various  neoplastic  growths  in  many  different 
situations  may  have  some  relation  to  embryonic  rests;  but  as 
these  are  now  known  to  exist  in  every  one  at  birth,  and  even 
in  large  numbers,  it  does  not  explain  why  one  or  more  of  them 
take  on  malignancy  only  in  later  periods  of  life.  Nor  are 
cancerous  lesion  always  or  commonly  associated  with  such. 

Some  have  attributed  cancer  to  independent  cell  action, 
relating  to  a  changed  polarity  in  the  cells,  etc.  But  it  is 
inconceivable  that  a  cell  or  cells  can,  of  their  own  volition 
start  out  on  a  rampant  course,  and  pursue  it  with  increas- 
ing severity,  even  until  death  results,  without  some  definite 
cause,  which  rationally  would  seem  to  be  the  vitiated  character 
of  the  blood  by  which  they  were  nourished. 

So  in  all  these  studies,  histologic,  bio-chemic,  etc.,  we  are 
forced  to  look  back  to  a  faulty  metabolism,  which  furnishes 

1  Williams,  "Diseases  of  the  Breast,  with  Special  Reference  to  Cancer." 
London,  1894,  p.  138. 

2  Ewing,  "Neoplastic  Diseases.''     New  York,  1919,  p.  94. 


METABOLISM  OF  CANCER  139 

nutriment  improper  to  the  satisfactory  growth  of  certain  cells 
which  compose  the  organism.  This  is  often  shown  by  the 
marvellous  restorative  effect  of  treatment  based  on  this  thesis, 
both  in  early  cancer,  even  with  developed  adenopathy,  which 
recedes  and  remains  absent  without  surgical  aid,  and  in  the 
great  benefits  often  seen  in  well  developed,  and  even  in  post- 
operative, recurrent  cancer,  as  will  be  detailed  later.  We  will 
now  consider  some  of  the  evidences  of  faulty  metabolism  as 
observed  in  cancer  patients. 

That  the  blood  shows  great  changes  in  advanced  cancer  is 
recognized  by  all,  and  is  clinically  manifested  by  the  intense 
cachexia  and  anaemia  commonly  present,  and  always  strongly 
marked  toward  the  end.  When  then  examined  there  is  found 
to  be  a  marked  reduction  of  red  cells,  low  haemoglobin  index, 
and  distinct  leucocytosis,  with  greatly  diminished  alkalescence. 
Some  consideration  of  this  subject  has  already  been  given  in 
the  preceding  chapter,  which  need  not  be  repeated  here.  The 
interesting  and  valuable  experiments  of  Hugh  Campbell  Ross1 
and  others  have  thrown  light  on  the  changes  which  take  place 
in  the  cells  of  the  blood  and  tissues,  as  mentioned  in  the  last 
chapter.  His  studies  explain  also  in  a  measure  the  continuance 
of  the  morbid  process  in  the  blood  and  tissues  where  the  disease 
has  been  carried  by  metastasis. 

The  reported  changes  in  the  blood  have  varied  with  the 
location  of  the  malignant  disease,  according  as  it  may  interfere 
mechanically  or  otherwise  with  the  function  of  other  organs, 
which  fact  naturally  obscures  the  question  of  the  true  relation- 
ship of  the  blood  to  cancer.  Thus,  it  is  stated  that  in  cancer 
of  the  liver  and  pancreas  there  is  always  leucocytosis  and 
glycogen,  and  that  "  cancer  appears  to  interfere  greatly  with  the 
function  of  the  liver  as  a  destroyer  of  intestinal  toxins,  they, 
passing  into  the  general  [circulation,  probably  cause  the 
glycogen,  reaction  and  at  least  part  of  the  leucocytosis." 

There  are  also  other  microscopical  alterations  in  the  blood  in 

1  Ross,  "Induced  Cell  Reproduction  and  Cancer."  Philadelphia,  ion,  pp. 
349ff. 


140  CANCER 

late  cancer.  Thus  degenerative  changes  in  the  leucocytes  are 
common,  with  derangement  in  the  normal  proportion  of  their 
different  forms,  as  also  changes  in  the  erethrocytes,  with 
nucleated  red  cells  and  megalocytes  in  severest  cases. 

Price  Jones,1  in  a  study  of  the  blood  in  30  cases  of  cancer 
(9  of  the  breast),  found  the  red  cells  diminished  on  an  average 
of  6  per  cent,  the  white  blood  cells  increased  38  per  cent,  lym- 
phocytes increased  by  10  per  cent,  large  mononuclear  cells  in- 
creased 164  per  cent,  and  polynuclears  42  per  cent.  Burnham 
states  that  in  the  severe  grades  of  anaemia  with  malignant  disease 
poikilocytosis  is  marked,  and  nucleated  cells  of  both  normo- 
blastic and  megaloblastic  type  may  be  present.  The  red 
corpuscles  may  be  reduced  to  2,500,000,  and  exceptionally  to 
1,000,000.  Cohnreich  in  a  very  technical  study  of  blood  from 
cancer  subjects,  observed  very  great  increase  in  the  resisting 
power  of  the  red  blood  cells  to  osmotic  tension,  in  regard  to 
their  haemoglobin,  which  he  believed  to  be  of  diagnostic  value 
in  doubtful  cases. 

O.  C.  Gruner2  has  gone  further  than  many  others,  and  has 
attempted  to  demonstrate  the  possibility  of  an  "exact  diagnosis 
of  latent  cancer"  by  means  of  the  blood.  He  says:  "Every 
gradation  of  blood  state,  be  it  physiological  or  para-physiological, 
is  faithfully  reflected  in  morphological  characters,  so  that  the 
blood  provides  an  expression  of  the  final  effect  of  a  number  of 
circumstances  which  have  been  gradually  converging  at  dif- 
ferent velocities,  toward  that  spot  on  the  highway  of  our 
neighbor's  life,  called  'the  present  moment.'" 

"The  para-physiological  states  differ  from  the  physiological 
only  in  their  being  deflections  from  routine  metabolic  tendencies. 
These  deflections  are  manifested  in  the  substrata  of  the  various 
orders  of  cells,  and  concern  the  proteins,  carbohydrates,  fat,  and 
salts.  They  are,  in  their  turn,  traceable  to  a  series  of  sequent 
influences  contributed  by  a  number  of  synchronous  factors 
provided  by  the  tout  ensemble  of  the  organs  and  tissues  of  which 

1  Jones,  "Archives  Middlesex  Hospital."      London,  1911,  p.  72. 

2  Gruner,  "The  Exact  Diagnosis  of  Latent  Cancer."     Philadelphia,  1919,  p.  2. 


METABOLISM  OF  CANCER  141 

our  body  is  composed.  Functional  inadequacies  or  errors  in 
the  ductless  glands,  in  the  sympathetic  nervous  system,  and 
even  in  the  mental  state  are  contributory  .  .  .  Pathology,  and 
therefore  physiology,  must  advance  beyond  the  cellular  doctrine 
to  perceive  'elements'  more  fundamental,  if  more  elusive. 

"Once  we  grasp  the  existence  of  deeper  principles,  the  more 
surely  shall  we  see  that  every  other  diagnostic  problem  can 
yield  to  the  same  mode  of  attack.  The  precision  is  gained  only 
at  the  expense  of  a  thousand  fold  increase  of  depth  of  knowledge 
concerning  the  intimate  processes  of  physiology.  The  relation 
between  every  organ  and  the  composition  of  the  blood  must  be 
worked  out.  However  simple  the  technique  may  appear,  or 
however  few  the  immediate  data  acquired,  the  fact  remains  that 
there  is  a  need  of  so  detailed  complex  of  knowledge  that  the 
fullest  intellectual  energies  will  be  taxed  before  it  is  achieved." 

It  is  impossible  to  present  briefly  even  the  salient  features  of 
his  interesting  study,  which  is  pretty  technical.  After  com- 
paring blood  from  a  cancer  patient  with  that  from  those  with 
many  other  forms  of  disease,  he  presents  tables  and  illustrations 
showing  the  differences  along  many  lines,  and  believes  that  with 
sufficient  patience  and  care,  with  knowledge  and  experience 
in  haemotology,  it  can  be  discovered  if  a  patient  has  cancer 
before  an  operation,  or  if  the  tendency  to  cancer  still  exists 
thereafter. 

Unfortunately  there  have  been  relatively  few  satisfactory 
studies  of  the  plasma  of  the  blood  in  cancer  or  other  diseases. 
And  yet  the  condition  of  this  fluid  must  be  of  the  utmost  import- 
ance, inasmuch  as  from  it  are  derived,  not  only  the  solid  con- 
stituents of  the  blood,  but  also  those  of  the  entire  system,  about 
8  per  cent  of  it  being  serum  albumen  and  serum  globulin,  to- 
gether with  certain  salts,  sugar,  fatty  matter,  and  gases.  It 
also  holds  in  solution  inorganic  salts,  phosphates,  carbonates, 
sulphates,  and  chlorides,  the  latter  often  varying  greatly,  and 
being  chiefly  responsible  for  the  isotonic  relation  of  cells  and 
serum.  A  high  percentage  of  chlorides  is  usual  in  anasmias,  such 
as  that  of  cancer.     The  reaction  should  be  alkaline,  but  in 


142  CANCER 

cancerous  cachexia  a  diminution  of  carbonic  acid,  a  constantly 
diminishing  alkalinity,  and  an  increase  of  acid  principle  in  the 
blood  have  been  fully  demonstrated,  pointing  in  all  probability 
to  the  existence  of  an  acid  intoxication. 

It  must  be  remembered  that  the  whole  volume  of  the  blood 
has  constantly  added  to  it,  through  the  absorbent  veins  and 
lymphatics,  quantities  of  partially  assimilated  substances,  which 
have  not  yet  undergone  the  transformation  produced  in  them 
by  all  the  various  organs  of  the  body:  for  instance  the  proteins 
have  been  but  imperfectly  split  up  into  their  end  products,  the 
amino-acids,  urea,  etc.  Thus  far  the  gastric,  intestinal,  and 
lymphatic  glands  are  the  only  agencies  which  have  acted  upon 
the  various  crude  substances,  as  is  seen  by  the  difference  in 
composition  of  the  venous  and  arterial  blood. 

When  we  consider  the  large  size  of  the  abdominal  aorta  and 
the  relatively  small  size  of  the  arterial  branches  given  off  to  the 
kidneys,  by  which  the  poisonous  elements  are  filtered  off,  we 
appreciate  that  the  purification  of  the  blood  stream  by  that 
organ,  by  which  nearly  all  of  the  nitrogen  waste  is  eliminated, 
must  be  very  slow.  It  has  been  estimated  that  of  the  total  quan- 
tity of  blood  sent  out  of  the  heart  in  a  minute,  only  about  5  per 
cent  may  pass  through  the  kidneys. 

The  formation  of  the  corpuscular  elements  of  the  blood,  also, 
must  be  greatly  interfered  with  when  metastases  occur  in  the 
blood-forming  and  blood-destroying  organs,  the  lymphatic  tis- 
sue, bone  marrow,  spleen,  and  liver;  for  it  has  been  estimated 
that  the  total  duration  of  life  of  each  individual  red  corpuscle 
cannot  exceed  ten  days.  It  seems  also  that  the  toxic  hormone 
or  secretion  from  the  cells  of  a  cancerous  mass,  has  a  distinctive, 
harmful  action  on  the  blood:  for  after  surgical  removal  of  a 
malignant  tumor  there  is  often  observed  an  increase  of  haemo- 
globin, as  I  have  witnessed,  also  a  high  leucocytosis  has  dis- 
appeared after  the  surgical  removal  of  a  scirrhus  of  the  breast, 
only  to  return  again  with  recurrence  of  the  tumor.  Abder- 
halden1  states  that  in  from  2  to  3  weeks  after  the  operative 

1  Abderhalden,  "Defensive  Ferments."     New  York,  1914. 


METABOLISM  OF  CANCER  143 

removal  of  cancer,  certain  defensive  ferments  can  no  longer  be 
found  in  the  serum  of  the  blood. 

Many  laboratory  studies  have  been  made  upon  the  chemistry 
of  cancer  tissue,  some  of  them  detailed  in  former  chapters,  seek- 
ing to  determine  the  nature  of  the  toxins  produced  by  cancer 
growth,  and  its  experimental  effect  on  animals,  but  thus  far  no 
great  results  have  been  obtained.  It  has  been  observed,  how- 
ever, by  Gruner1  that  when  cancer-juice  is  injected  intraven- 
ously a  marked  lymphocytosis  arises,  which  is  followed  by  the 
appearance  of  large  mast-cell  myelocytes  in  the  blood.  The 
cancer  juice  is  supposed  to  be  auto-toxic  in  cancer  patients,  and 
comprises  toxic  albuminoids,  which,  being  in  quantities  too 
great  to  be  quickly  neutralized,  poison  the  system,  especially 
the  blood  and  the  hemopoietic  organs. 

It  is  hardly  possible  to  draw  a  line  between  the  blood  and 
nutrition  in  the  precancerous  period  and  in  latent  cancer  on 
the  one  hand,  and  in  the  early  stages  of  cancer  on  the  other:  nor 
between  the  latter  period  and  the  period  of  cachexia.  The 
metabolism  in  cancer  tissue  must  not  be  confounded  with  the 
metabolism  of  the  cancerous  individual.  The  blood  is  believed 
to  contain  antibodies  which  can  protect  it  from  cancer,  some- 
what as  the  pregnant  woman  is  protected  against  chorioepithe- 
lioma  of  the  uterus.  As  soon  as  delivery  has  occurred  she 
continues,  as  a  rule,  to  enjoy  protection,  but  in  the  exceptional 
case  she  develops  this  form  of  malignancy.  The  source  of  the 
protection  may  lie  in  the  ovary,  for  when  this  disease  develops 
there  is  said  to  be  some  disturbance  in  the  production  or  reten- 
tion of  lutein  substance.  In  cancer  we  may  suppose  that  a 
similar  mechanism  is  at  work,  and  that  the  failure  of  protection 
may  coincide  with  the  disappearance  of  some  substance  from  the 
blood. 

The  work  in  the  Mayo  clinic  in  regard  to  cholesterol  appears 
to  show  that  this  substance  is  in  excess  in  subjects  who  later 
develop  cancer,  while  it  is  also  thought  that  sugar  tolerance  is 
diminished  under  the  same  conditions. 

1  Gruner,  "Biology  of  the  Blood  Cells."     1913,  pp.  153,  260. 


144  CANCER 

The  exhaustive  studies  of  the  blood  by  Gruner  suggest  that 
the  bloood  count  may  show  departures  from  normal  while 
cancer,  although  present,  is  inactive,  and  this  implies  that  similar 
alterations  may  occur  before  the  development  of  cancer  has 
occurred  at  all.  His  meaning  is  not  altogether  clear  but  he 
teaches  that  cancer,  the  disease,  precedes  cancer  the  local  mani- 
festation. There  is  also  a  poverty  of  blood  in  calcium  and  an 
excess  of  potassium,   according  to  some  laboratory  workers. 

The  presence  of  hemolysins,  enzymes,  toxins,  lysins,  etc.  has 
been  mentioned.  The  question  of  antibodies,  generated  in 
response  to  the  presence  of  cancer,  has  thus  far  not  been  men- 
tioned. There  is  enough  evidence  of  antibody  formation  to 
suggest  that  cancer  protein  differs  somewhat  from  tissue  protein. 
Injection  of  virulent  cancer  material  has  been  found  to  generate 
some  antibody  substance,  but  the  formation  is  low  and  incon- 
stant, and  the  specificity  is  not  marked.  That  antibodies  exist 
in  health  and  give  natural  immunity  is  not  proven.  Normal 
serum  does  not  dissolve  a  cancer  cell,  while  cancer  serum  does. 
Much  has  been  written  on  blood  cholesterol  in  cancer,  and  the 
excess  present  before  the  occurrence  of  the  tumor  suggests 
defective  oxidation;  Luden  believes  that  radium  benefits 
because  it  antagonizes  this  lipoid  excess. 

There  are  certain  facts  of  interest  concerning  cancer  anemia. 
It  is  twofold  in  character,  and  either  due  to  hemorrhage  or 
toxemia,  in  the  latter  case  being  caused  by  the  hemolysins 
formed  in  the  growth.  In  rare  cases  anemia  may  not  develop 
at  all,  as  has  been  noted  in  cancer  of  the  oesophagus;  or  a 
veritable  pernicious  anemia  may  be  set  up.  In  many  cases  of 
anemia  hemorrhage  is  the  cause,  nor  is  it  necessary  that  this 
be  manifest,  for  some  of  the  worst  cases  may  follow  occult 
hemorrhage.  In  such  cases  not  the  clinical  history  nor  symp- 
toms, but  the  characteristic  blood  count  of  hemorrhage  is 
decisive. 

In  order  for  cancer  products  to  cause  cachexia  it  is  not 
necessary  for  nutrition  to  suffer  first,  although  this  is  the  rule. 
Cachexia  is  called  the  sum  of  all  the  ill  consequences  of  cancer 


METABOLISM  OF  CANCER  145 

to  the  general  system.  It  is  said  not  to  be  specific,  and  to 
differ  in  no  essential  from  the  cachexia?  of  chronic  suppuration, 
chronic  loss  of  blood,  tuberculosis,  etc.,  but  cancer  is  the  most 
frequent  cause  and  produces  the  most  typical  form.  Authorities 
differ  as  to  the  operation  of  one  of  the  factors,  to  wit,  the  with- 
drawal of  the  body  nutriment  in  order  to  feed  the  cancer.  Wood 
does  not  mention  it,  although  others  regard  this  as  the  most 
essential  cause,  the  next  being  absorption  of  toxic  matter  after 
secondary  changes  have  occurred.  A  third  factor  is  anemia. 
In  certain  cases  sepsis  is  a  complication.  Still  another  is  local 
interference  with  vital  functions.  The  action  of  mental 
depression  at  the  hopelessness  of  recovery,  and  the  doom  of 
months  of  suffering,  is  sometimes  given  as  a  factor.  Cachexia 
clinically  is  characterized  chiefly  by  pallor  and  emaciation, 
with  marked  weakness.  The  patient  as  a  rule  has  no  appetite 
and  it  is  not  easy  to  feed  him.  It  is  not  now  believed  that 
cachexia  has  ever  preceded  cancer,  although  this  view  was  once 
held. 

Cachexia  may  follow  the  primary  tumor  or  may  not  appear 
until  the  metastases  have  begun.  Sometimes  removal  of  the 
primary  growth  has  led  to  the  disappearance  of  the  cachexia, 
the  latter  reappearing  with  recurrence  or  metastases.  As  a 
rule  cachexia  and  metastases  coexist,  but  either  may  be  present 
without  the  other.  Cachexia  never  seems  to  check  or  arrest 
the  growth  of  the  primary  or  secondary  tumors.  These 
continue  to  enlarge  until  the  last.  For  the  same  reason  cancer 
may  very  rarely  appear  in  the  course  of  cachexia  from  some 
other  cause — tuberculosis  for  example.  Even  when  all  outside 
nutriment  is  cut  off  the  tumor  growth  proceeds. 

The  metabolism  of  the  cachectic  individual  is  said  not  to 

differ  in  any  way  from  the  metabolism  in  cachexias  from  other 

causes.     While  according  to  the  Mayos  freshly  growing  cancer  is 

attended  by  production  of  acid  (increased  amino-acids?)  which 

extends   through   the   organism   and  is   a   factor  in  cachexia 

production,  it  seems  none  the  less  true  that  after  cachexia  is 

once  present  the  acid  content  of  the  body  is  lessened,  and  the 
10 


146  CANCER 

blood  alkalinity  increased.  This  occurs  in  any  cachexia,  and 
incidentally  is  shown  by  diminished  hydrochloric  acid  in 
the  stomach.  Demineralization  also  occurs,  all  of  the  saline 
content  diminishing  except  the  chlorides. 

Cachexia  however  only  kills  about  one  patient  out  of  three, 
for  the  occurrence  of  numerous  complications,  which  vary 
with  the  seat  of  the  disease,  is  the  cause  of  the  majority  of 
deaths — these  are  very  numerous  and  include  hemorrhage, 
inanition  from  obstruction,  sepsis,  albuminuria,  pneumonia, 
meningitis,  the  results  of  operation  and  so  on. 

We  will  now  consider  some  of  the  data  which  have  been  re- 
corded in  regard  to  the  secretions  and  excretions,  including  the 
internal  secretions,  in  cancer  patients,  as  they  furnish  the  means 
of  understanding  human  metabolism. 

Beebe1  has  said :  "  No  phase  of  metabolism  has  been  described 
as  cancerous  which  does  not  have  a  counterpart  in  non-can- 
cerous conditions.  This  applies  to  such  questions  as  the  nutri- 
tive relations  between  the  cancer  cells  and  the  normal  body 
tissue,  to  the  nitrogenous  balance,  retention  or  elimination  of 
sodium  chloride,  the  excretion  of  acetone,  the  relation  of 
ammonia  excertion,  and  a  possible  acidosis."  He  adds,  how- 
ever: "Diet  doubtless  forms  an  important  part  in  the  growth 
of  cancer,  possibly  even  in  the  origin  of  the  disease."  It  is 
encouraging  to  find  that  this  able  and  careful  laboratory  investi- 
gator recognizes,  in  a  measure,  the  basic  cause  of  diet,  towards 
which  all  evidence  points  so  strongly,  although  its  definite 
connection  may  not  yet  have  been  established  by  laboratory 
methods. 

The  urine  has  been  the  object  of  much  study  in  connection 
with  cancer,  as  it  would  naturally  be  expected  to  reflect  the 
metabolic  changes  in  this  disease,  as  it  does  in  others.  While 
many  departures  from  the  normal  are  constantly  observed,  and 
while  under  complete  volumetric  analysis  of  the  urine  of  a 
cancer  subject,  it  is  rarely  if  ever  found  to  be  that  of  perfect 
health,  it  cannot  be  said  that  any  definite  and  specific  changes 

1  Beebe,  New  York  Medical  Journal,  igio,  p.  1058. 


METABOLISM  OF  CANCER  147 

have  been  established  which  may  not  be  found  in  those  without 
cancer;  although  there  have  been  several  who  have  so  asserted 
and  have  even  claimed  to  have  found  diagnostic  signs  of  cancer 
in  the  urine. 

But  minute,  repeated,  volumetric  analysis  is  often  of  great 
service  in  guiding  the  nutrition  and  medication  of  these 
patients,  and  gross  urinary  errors  are  constantly  met  with 
which  may  have  the  greatest  bearing  on  the  case  in  hand,  as 
indicating  very  important  metabolic  disturbance;  and  treat- 
ment, to  be  thoroughly  effectual,  must  be  based  on  the  study 
and  recognition  of  these  elements,  and  adjusted  accordingly. 

It  must  be  remembered  that  while  the  kidneys  are  one  of 
the  main  excretory  agents  of  the  system,  carrying  off  daily  in 
health  between  6  and  7  grains  of  solid  matter  for  each  pound 
of  body  weight,  their  secretion,  the  urine,  is  very  complex  in  its 
composition  of  over  a  dozen  ingredients,  and  can  afford  invaluable 
indications  as  to  the  systemic  derangements  existing  and  their 
necessary  correction  in  cancer.  As  the  urine  comes  directly 
from  the  arterial  blood,  and  there  are  only  two  layers  of  epithe- 
lial cells  in  the  Malpighian  tufts,  between  the  interior  of  the 
capillaries  and  the  uriniferous  tubes,  through  which  the  urinary 
elements  filtrate,  I  have  been  accustomed  to  call  the  kidneys 
the  judge  and  jury  as  to  the  condition  of  the  blood;  when  the 
urine  is  most  carefully  analyzed  volumetrically  and  its  indica- 
tions correctly  interpreted.  This  does  not  relate  to  the  presence 
of  sugar,  albumin,  or  casts,  but  to  the  other  various  constituents. 
For  while  the  products  of  the  assimilation  and  dissimilation  of 
the  simple  carbohydrates  and  fats  pass  off  by  the  lungs,  generally 
without  harm,  those  of  the  protein  and  salts  are  eliminated  by 
the  kidneys,  and  as  is  known,  may  be  the  cause  of  various 
systemic  derangements.  From  the  study  of  hundreds  of 
complete  volumetric  analyses  in  scores  of  cancer  patients,  both 
in  the  very  early  and  late  stages  of  the  disease,  I  have  found 
that  this  excretion,  almost  invariably,  exhibits  departures  from 
normal  which  are  significant  and  helpful  to  know  and  act  upon. 

First    to    be  mentioned  is  the  relation  of   the  total  solids 


148 


CANCER 


excreted  daily  to  the  body  weight  of  the  individual:  for  it  is 
evident  that  a  person  weighing  200  lb.  should  pass  off  more 
than  a  smaller  person.  In  one  very  interesting  case  of  cancer 
of  the  breast,  in  a  stout,  flabby  lady,  near  55,  in  private  practice, 
the  total  quantity  of  the  urine,  measured  daily  for  weeks,  was 
always  far  below  the  normal  amount,  and  in  spite  of  diet  and 
active  medication  it  seemed  almost  impossible,  for  a  long  time 
to  raise  the  total  daily  quantity  of  solids  excreted  in  the  urine, 
to  more  than  one-half  of  that  called  for  by  weight  of  the  patient. 
In  cancer  I  seek  to  have  the  daily  output  somewhat  above  that 
of  a  normal  individual,  and  find  the  disease  improve  accordingly. 
The  following  table  represents  fairly  well  the  total  solids 
that  should  pass  daily  in  order  to  maintain  a  healthy 
equilibrium. 


Body  weight, 

Total  urinary 

Body  weight, 

Total  urinary 

pounds 

solids,  grains 

pounds 

solids,  grains 

90 

500 

1-50 

920 

95 

535 

155 

95S 

100 

570 

160 

990 

105 

605 

165 

1,025 

no 

640 

170 

1 ,060 

"5 

675 

175 

1,095 

120 

710 

180 

1,130 

125 

745 

185 

1,165 

130 

780 

190 

1 ,  200 

135 

815 

195 

1,235 

140 

850 

200 

1,270 

145 

885 

205 

1,305 

These  figures  do  not  represent  much  active  exercise,  and 
with  increased  bodily  exertion  the  solids  passed  should  be 
more.  This  table  was  really  constructed  for  women,  and  men 
should  excrete  perhaps  one-tenth  more  than  women:  there 
are  also  less  urinary  solids  passed  with  advancing  years,  and 
about  5  per  cent  may  be  deducted  from  each  10  years  after 
forty. 


METABOLISM  OF  CANCER  149 

The  estimation  of  the  total  solids  is  easy  with  Haines' 
modification  of  Haser's  method.  Multiply  the  last  two  figures 
of  the  specific  gravity  of  the  total  daily  urine  by  the  number  of  ounces 
voided  in  24  hours,  and  add  10  per  cent  to  the  product.  Thus,  if 
the  amount  passed  in  24  hr.  was  36  oz.  with  a  specific  gravity  of 
1,021,  it  would  be  36  X  21  =  756  +  10  per  cent>=  832  gr.  of  solids 
in  the  whole  amount  of  urine  excreted  that  day.  By  comparing 
this  figure  with  the  table  it  can  be  readily  ascertained  if  the 
amount  is  above  or  below  the  normal  standard  for  the  body 
weight  of  the  patient  as  judged  by  the  exact  weight  and  age. 

For  many  years  I  have  employed  this  method  of  determining 
the  urinary  output  in  hundreds  of  patients  with  various  diseases 
of  the  skin  and  cancer,  and  have  found  it  of  inestimable  value. 
It  is  understood,  of  course,  that  by  dietary  and  therapeutical 
measures  the  urinary  solids  are  to  be  brought  up  to  and 
maintained  at  or  above  normal. 

As  before  remarked  in  regard  to  the  elements  in  the  study  of 
the  disease,  it  would  be  very  desirable  to  have  a  knowledge  of 
the  urine  in  pre-cancerous  stages,  and  also  in  very  early  cancer, 
likewise  after  surgical  operations,  that  we  might  better  under- 
stand the  metabolic  changes  which  lead  up  to  malignant  disease. 
But  unfortunately  these  are  very  few,  if  they  exist  at  all,  and 
almost  all  the  studies  on  the  urine  have  been  made  in  advanced 
cancer,  and  often  when  the  disease  has  affected  vital  organs, 
or  when  by  its  own  poison  it  has  disturbed  the  workings  of  the 
economy.  For,  as  will  be  shortly  noticed  in  regard  to  bowel 
action,  deficient  body  elimination,  often  of  long  standing,  is 
most  certainly  at  the  bottom  of  cancer,  although  subjects  will 
often  appear  in  blooming  health  before  the  insidious  process 
has  been  detected. 

The  acidity  of  the  urine,  as  measured  by  the  oxalic  acid  and 
phenophthalein  test  is  also  of  the  greatest  importance.  This 
is  not  difficult  or  tedious  of  application,  and  has  been  used 
daily  in  my  laboratory  for  years:  the  litmus  test  is  of  relatively 
little  value  in  comparison  with  an  actual  chemical  measurement. 
Thus  with  an  average  normal  standard  of  285  to  300,  we  not 


150  CANCER 

infrequently  find  an  acidity  of  500  or  600,  or  even  1,000,  and 
I  have  known  it  1,200;  or  it  may  sink  to  200  or  100,  or  even  be 
strongly  alkaline.  As  this  urine  comes  directly  from  the  sub- 
stances circulating  in  the  arterial  blood,  which  the  kidneys  are 
striving,  often  in  vain,  to  remove  or  keep  down,  it,  most  surely, 
must  make  a  great  difference  to  nutrition  whether  the  alkales- 
cence of  the  blood  is  normal,  as  reported  by  the  urine  at  300,  or 
whether  the  acid  element  is  doubled  or  even  quadrupled.  In 
cancer  I  have  striven  to  keep  the  urinary  acidity,  by  diet  and 
remedies,  a  little  below  normal,  as  it  has  been  shown  that  the 
blood  in  the  disease  exhibits  a  constantly  increasing  tendency 
to  diminished  alkalescence,  or,  wrongly  called,  increased  acidity. 
We  know  the  result  of  acidosis  in  diabetes. 

Proteid  metabolism  has  been  found  by  many  observers  to  be 
greatly  disturbed  in  cancer,  and  dependent  on  this  many 
deviations  from  normal  are  found  in  the  urine. 

A  number  of  studies  have  been  made  upon  the  nitrogen 
partition  in  the  urine  of  cancer  patients  by  Einhorn,  Kahn, 
and  Rosenblum,1  also  by  de  Bloeme,2  Sweet,  and  others,  show- 
ing and  increase  in  colloid  nitrogen  to  more  than  double  the 
normal  amount,  increased  eb'mination  of  xanthin,  oxyproteic 
acid,  and  urinary  ammonia,  together  with  many  other  changes 
which  show  that  disintegration  of  the  protein  elements  is  very 
imperfect  and  often  defective.  An  interesting  statement  is 
made  by  Blumenthal,3  that  the  oxyproteic  acids  are  increased 
even  in  very  early  cancer,  and  independently  of  the  size  of  the 
tumor  and  degree  of  cachexia,  showing  them  to  have  some 
specificity  for  cancer,  because  they  have  not  been  found  in 
other  forms  of  malignancy.  He  also  states  that  urobilin  is 
increased  in  a  large  proportion  of  cases  of  cancer,  especially 
when  cachexia  is  setting  in,  and  is  a  grave  symptom. 

Reid,4  who  has  confirmed  many  of  these  matters  reported 

1  Einhorn,  Kahn  and  Rosenblum,  Archiv.  f.  Verdauungsekr.,  191 1,  p.  557. 

2  Dr.  Bloeme,  Munch.  Med.  Wochenschr.,  1914,  p.  1718. 

3  Blumenthal,  Handb.  d.  Spezial,  Path.  d.  Harns.,  1913,  p.  263. 

4  Reid,  Cancer  Research  Lab.,  Manchester  Med.  Chron.,  Nov.,  1912;  April, 
1914. 


METABOLISM  OF  CANCER  151 

by  others,  says:  "I  have  found  an  increase  of  amino-acid 
nitrogen  in  practically  every  case  of  cancer  I  have  examined. 
.  .  .  .Hence  we  can  only  infer  that  in  cancer,  the  liver, 
while  not  involved  in  the  disease,  is  still  unable,  for  some  reason, 
to  perform  its  function  in  synthetizing  urea.  The  organ  is 
functionally  injured,  no  lesions  having  been  found  to  explain 
its  insufficiency;  or  possibly  cancerous  subjects  form  proteids 
which  the  liver  is  unable  to  deal  with,  so  they  are  excreted 
unchanged,  or  nearly  so.  "Degres1  has  made  confirmatory 
studies  along  these  lines,  and  found  the  nitrogen  disintegration 
very  imperfect,  with  increase  of  the  ammonia  fraction  of  nitro- 
gen and  increased  elimination  of  xanthin  bases.  He  states 
that:  "the  toxicity  of  the  urine  is  increased,  apparently  as 
the  result  of  the  presence  of  substances  which  have  not  been 
fully  oxidized." 

The  urea  is  almost  invariably  diminished,  often  very  greatly, 
as  I  have  verified  time  and  again,  in  many  cases. 

Sulphur  elements  have  been  recorded  as  exhibiting  notable 
changes  in  the  urine  of  cancer  patients.  These  are,  a  great 
increase  in  neutral  (unoxidized)  sulphur,  and  a  considerable 
excess  of  sulpho-cyanic  acid,  together  with  an  increase  in 
sulphates    and    indican,    which    I    have    constantly  observed. 

The  chlorides,  on  the  other  hand,  are  as  a  rule  diminished  in 
the  urine  of  cancer,  especially  in  its  late  stages,  when  there  is 
inanition  or  kidney  insufficiency:  and  probably  any  change  in 
these  has  only  a  relation  to  the  nutrition  of  the  patients,  for  the 
chlorides  come  from  the  food,  and  are  commonly  an  index  of  the 
amount  of  nutriment  absorbed.  Robin2  finds  some  relation 
between  the  excretion  of  chlorine  and  nitrogen,  according  to  the 
stage  in  which  the  system  is  affected  by  cancer. 

The  phosphates  are  known  to  be  increased  in  the  urine  of 
cancer  subjects,  although  irregularly  and  in  an  inverse  ratio 
to  the  chlorides.  As  inanition  increases  there  is  a  greater 
autolysis  of  cellular  structures,  and  the  nuclei  yield  an  excess 

1  Degres,  Gaz.  Med.  de  Paris,  1913,  p.  400. 

2  Robin,  Bull.  Gen.  de  Therapeutique,  1913,  clxvi,  p.  433. 


15-1  CANCER 

of  phosphates,  which  are  excreted  in  the  urine.  A  more  or  less 
general  demineralization  of  the  system  through  the  urine  has 
been  observed  by  several,  and  has  been  recognized  as  a  signifi- 
cant matter,  which  is  of  special  importance  when  we  consider 
what  an  important  part  minerals  take  in  the  nourishment  of 
cell  life. 

While  the  changes  which  have  been  observed  in  the  urine  in 
connection  with  cancer  are  not  wholly  pathognomonic,  but  occur 
in  connection  with  other  diseased  states  of  the  system,  so  that 
few  if  any  of  them  can  be  accepted  as  diagnostic,  or  productive 
of  malignant  disease,  they  all  have  a  certain  significance,  as 
indicating  the  metabolic  changes  which  accompany  and,  as 
we  believe,  have  much  to  do  with  its  nature  and  etiology:  and, 
as  stated  before,  a  careful,  systematic,  and  frequently  repeated 
volumetrical  analysis  of  the  urine  certainly  assists  greatly  in 
the  proper  management  of  these  cases,  when  the  departures 
from  normal  are  carefully  studied  and  correctly  interpreted, 
and  acted  upon  intelligently. 

The  saliva,  by  its  action,  constitutes  a  very  important  element 
in  the  process  of  digestion,  and  consequently  has  its  influence 
on  metabolism  and  the  genesis  of  cancer.  Far  too  little  atten- 
tion has  been  paid  scientifically  to  this  secretion,  in  ordinary 
life  or  in  disease,  although  there  have  been  laboratory  studies 
on  its  physiological  action.  And  yet  the  experience  of  Mr. 
Fletcher  and  others  have  demonstrated  wonderful  results  from 
perfect  mastication  and  thorough  insalivation,  and  a  careful 
consideration  of  the  processes  of  digestion  must  convince 
every  one  of  the  importance  of  this  secretion  in  connection 
with  nutrition,  both  in  health  and  disease.  In  Mr.  Fletcher's 
case  he  was  able  to  reduce  his  own  body  weight  over  fifty 
pounds,  largely  abdominal  fat,  solely  by  very  perfect  and  pro- 
longed mastication.  Many  have  observed  a  connection  between 
obesity  and  cancer.  The  unsatisfactory  ultimate  results 
of  operations  on  cancer  occurring  in  fat  subjects  is  well  known, 
and  often  dwelt  upon  by  the  late  Dr.  John  B.  Murphy,  and 
the  perfect  transformation  of  carbohydrates  and  fatty  sub- 


METABOLISM  OF  CANCER  1 53 

stances  by  the  proper  and  sufficient  use  of  the  salivary  secretion 
may  prove  to  be  an  important  element  in  the  prophylaxis  and 
cure  of  cancer.  The  salivary  secretion  has  been  found  by  me 
to  be  so  constantly  acid,  and  often  strongly  so,  even  in  very 
early  cancer,  and  almost  invariably  in  cancer  of  the  buccal 
cavity,  that  I  cannot  but  believe  that  this  condition  has  some 
bearing  upon  the  subject  which  we  are  studying.  Not  only 
have  I  observed  it  in  dozens  of  patients  in  my  office,  but  in  the 
New  York  Skin  and  Cancer  Hospital  I  have  had  hundreds  of 
testings  made  and  recorded,  as  a  daily  routine,  quarter  of  an 
hour  before  eating  and  quarter  of  an  hour  after  eating,  and  rarely 
is  it  other  than  acid,  until  altered  by  treatment.  As  dietary 
and  other  treatment,  with  proper  mastication,  is  carried  on 
rightly,  followed  by  improvement  in  the  cancer  mass,  the 
saliva  returns  to  its  normal  alkalinity,  but  with  a  tendency  to 
relapse  into  an  acid  condition  when  there  is  any  laxness  in  the 
measures  employed. 

It  is  interesting  in  this  connection  that  Dr.  W.  J.  Mayo  has 
called  our  attention  to  the  fact  that  cancer  is  apt  to  develop  in 
regions  exhibiting  an  acid  reaction.  Thus,  while  it  is  frequent 
in  the  acid  stomach  it  is  absent  in  the  alkaline  duodenum,  and 
again  common  in  the  acid  colon:  it  is  also  frequent  in  the 
bladder  under  certain  acid  conditions. 

It  is  to  be  remembered  that  the  saliva,  which  amounts  in 
health  to  between  one  and  two  quarts  daily,  varying  with  the 
food,  etc.,  is  not  wholly  for  the  purpose  of  lubricating  the  mouth 
and  facilitating  deglution,  but  its  enzymes,  ptyalin  and  maltase, 
effect  radical  and  important  changes  in  the  starchy  matter 
consumed.  It  is  also  to  be  remembered  that  the  latter  cannot 
be  acted  upon  by  the  acid  stomach  secretions,  but,  if  the 
salivary  digestion  has  been  imperfect,  through  insufficient 
or  imperfect  mastication,  such  carbonaceous  substances  must 
be  passed  on  to  the  influence  of  the  pancreatic  fluid  in  the 
small  intestine.  Hence  there  follows  delayed  and  imperfect 
digestion,  faulty  metabolism,  deranged  nutrition,  and  possibly 
tumor  growth.     The  importance,  therefore,  of  very  slow  eating, 


154  CANCER 

very  thorough  mastication,  and  perfect  insalivation  cannot  be 
too  strongly  insisted  on,  both  as  an  clement  in  the  prevention 
of  cancer  and  also  as  a  curative  measure,  when  it  has  developed. 

Imperfect  intestinal  elimination  is  constantly  observed  in 
cancer  cases,  both  habitually  both  before  and  in  the  very  early, 
formative  period,  and  also  later,  even  before  any  recourse  to 
morphine,  which,  of  course,  heightens  the  trouble.  In  question- 
ing these  patients  closely,  and  recording  their  statements,  I 
have  been  so  struck  with  the  almost  invariable  history  of 
constipation,  or  at  least  imperfect  intestinal  elimination,  that 
I  cannot  help  feeling  very  strongly  the  probability  that  the 
toxins  produced  by  the  millions  of  micro-organisms  generated 
through  intestinal  stasis  and  fecal  putrefaction,  play  a  great 
part  in  the  production  of  that  blood  dyscrasia  which  culminates 
in  the  formation  of  the  malignant  growth.  Sir  Arbuthnot 
Lane,  of  London,  has  emphasized  the  fact  that  one  of  the 
terminal  results  of  intestinal  stasis  may  be  cancer.  Dr.  Robert 
Bell,1  of  London,  also,  originally  a  surgeon  operating  largely 
on  cancer,  is  most  strong  on  this  subject,  and  says:  ''During 
a  period,  now  extending  over  20  years,  that  I  have  devoted 
special  attention  to  this  subject,  with  ample  opportunity  at  my 
command  for  observation,  I  have  never  met  with  a  single 
instance  where  constipation  did  not  exist,  and,  moreover,  had 
not  been  in  evidence  for  a  lengthened  period  prior  to  the 
manifestation  of  the  disease,"  and  he  dwells  at  some  length  on 
the  necessity  of  a  daily  and  complete  evacuation  of  the  bowels. 

I,  myself,  am  even  more  strenuous  in  regard  to  this  matter, 
and  spend  much  time  making  the  subject  clear  to  patients,  and, 
as  in  the  case  of  the  urine  I  endeavor  to  have  the  solid  urinary 
excreta  a  little  above  normal,  and  the  acidity  also  even  below 
normal,  so  with  the  intestinal  excreta,  I  prefer  that  they  shall 
be  in  excess  rather  than  possibly  deficient.  Under  a  proper 
vegetarian  diet  there  is  less  likelihood  of  trouble,  but  even  then 
there  should  be  at  least  one  full,  free  movement  of  normal 
character  daily,  and  certainly  one  immediately  after  breakfast. 

1  Bell,  Cancer,  Its  Cause  and  Treatment  without  Operation.     London,  1913. 


METABOLISM  OF  CANCER  1 55 

The  internal  secretions,  so  called,  have  also  been  the  subject 
of  much  research  and  speculation  of  late  years,  in  regard  to 
their  influence  on  metabolism  and  the  life  processes  of  the 
economy,  and  many  studies  have  been  made  concerning  their 
connection  with  cancer,  so  that  there  seems  to  be  little  doubt 
but  that  the  secretions  of  the  ductless  glands  in  common  have 
much  to  do  with  regulating  the  metabolism  of  the  cells.  We 
know,  for  instance,  that  disease  of  the  pituitary  body  produces 
bone  disease,  resulting  in  gigantism :  that  thyroid  derangement 
results  in  myxcedema:  and  that  disease  of  the  supra-renal 
capsules  gives  rise  to  Addison's  disease,  or  bronzed  skin.  It 
is  not  impossible,  therefore,  that  the  derangement  of  secretion 
of  one  or  more  of  these,  or  other  organs,  may  be  an  element  in 
the  disordered  action  of  certain  epithelial  cells,  resulting  in 
cancer.  Harrower  calls  attention  to  the  fact  that  cancer  is 
essentially  a  disease  of  that  period  of  life  when  certain  of  the 
endocrinous  glands  lose  their  normal  functions,  this  loss  entailing 
related  changes  in  the  whole  chain  of  interrelated  functions  of 
the  ductless  glands. 

The  Thymus  Gland. — This  is  a  ductless  gland  of  early  extra- 
uterine life,  slowly  retrograding,  until  by  the  twentieth  year 
scarcely  a  vestige  of  glandular  tissue  remains.  It  originates  in 
the  entoderm  and  begins  its  fcetal  existence  as  a  typical  gland. 
Into  this  epithelial  structure  mesodermic  cells  grow  and  differ- 
entiate into  lymphatic  tissue  (Bailey).1  Forbes  Ross,2  in  his 
interesting  and  instructive  book,  makes  some  reasonable 
suggestions  as  to  its  influence  in  protecting  young  life  from 
cancer.  He  administered  thymus  gland  tablets  to  some 
inoperable  cancer  cases  and  was  appalled  at  the  colossal  increase 
of  growth  which  followed;  in  two  or  three  weeks  the  tumors 
had  quadrupled  in  size  and  the  conditions  of  the  patients  were 
very  much  worse.  The  same  occurred  when  he  gave  calcium 
salts  freely  to  other  similar  cases.  He  reasoned  that  in  early 
life  calcium  was  freely  used  in  the  ossification  of  bones,  over 

1  Bailey,  A  Text-book  of  Histology.     New  York,  1010,  p.  153. 

2  Ross,  Cancer,  the  Problem  of  Its  Genesis  and  Treatment.    London,  191 2. 


156  CANCER 

which  process,  the  thymus  presided.  He  calls  attention  to 
the  fact  that  mesoblastic  tissue  disease,  sarcoma,  is  far  more 
common  in  early  life  than  epiblastic,  or  epithelial  neo-plasms, 
and  that  in  adult  life  sarcoma  is  very  liable  to  originate  from 
bony  structures,  having  relation  to  calcium.  His  study  of 
the  relations  of  the  four  principal  salts  of  the  body,  calcium, 
magnesium,  sodium,  and  potassium,  to  disease  is  very 
suggestive. 

The  pituitary  gland  is  also  an  organ  whose  internal  secretion 
has  to  do  with  cellular  action,  as  already  alluded  to  in  its 
connection  with  gigantism,  and  therefore  with  the  handling  of 
calcium  in  the  system.  But  I  have  been  unable  to  find  any 
satisfactory  reports  of  its  action  in  relation  to  cancer. 

The  thyroid  is  now  recognized  as  playing  an  important  part  in 
assisting  metabolism,  and  like  the  adrenals  and  pituitary,  its 
complete  removal  with  the  para-thyroids,  in  animals,  is  followed 
by  death.  While  the  study  of  the  hormones  is  still  in  its 
infancy,  there  seems  to  be  no  question  but  that  the  endocrinous 
glands  act  conjointly,  one  influencing  the  other,  and  that 
together  they  exert  a  very  great  influence  in  the  life  processes 
of  the  body,  and  on  the  behaviour  of  its  component  cells. 
The  thyroid  has  been  shown  to  be  one  of  the  main  factors,  in 
the  post-thymus  period,  in  the  management  of  calcium  within 
the  body,  which  mineral  is  believed  to  be  an  element  in  cancer, 
and  it  also  enhances  the  metabolism  of  toxic  wastes,  which  are 
etiological  factors  in  this  disease.  Many  have  reported  favor- 
ably on  the  effect  of  thyroid  feeding  in  this  disease,  and  after  an 
experience  with  it  in  many  cases,  I  am  convinced  that  it  has 
been  one  of  the  means  which  contributed  to  the  good  results 
obtained.  Bell  is  particularly  strong  on  this  subject,  and 
reports  many  cases  where  the  results  were  most  striking, 
believing  that  the  thyroid  has  a  peculiar  and  particular  control 
over  epidermic  cells. 

The  internal  secretions  of  the  testicles  and  ovaries  are  also 
thought  to  have  some  share  in  metabolic  processes,  and  obser- 
vations have  been  made  in  regard  to  their  influence  in  cancer. 


METABOLISM  OF  CANCER  157 

Thus,  Cahen1  reported  that  Beatson's  operation  of  removal  of 
the  ovaries  for  inoperable  cancer  of  the  breast,  first  done  in 
1896,  has  been  repeated  by  many,  so  that  Lott  has  reported  96 
cases,  including  his  own.  Of  these  in  23.2  per  cent  the  oper- 
ation caused  a  distinct  improvement  in  the  cancer.  In  15 
cases  the  improvement  persisted  for  a  year,  in  four  cases  for 
4}i  years,  and  in  one  case  for  over  5  years.  Cahen  operated 
on  seven  women  with  remarkable  results :  in  two  cases,  life  was 
prolonged  4  and  6  years  respectively.  Others,  however,  have 
shown  by  statistics,  that  damage  to  the  ovaries  by  disease,  or 
their  removal  by  operation,  greatly  increases  the  proclivity  to 
cancer. 

Several  writers  have  connected  cancer  with  the  waning  of  the 
sexual  powers,  and  the  suggestion  is  made  by  Sherrington  and 
Copeman2  that  in  the  period  which  antedates  the  cancer  age, 
the  reproductive  glands  by  means  of  internal  secretions  are  able 
to  inhibit  the  growth  of  cancer. 

Whitman  of  the  Dennison  Research  Fund,  has  published  a  new 
view  of  cancer  which  seems  merely  a  verbal  one  and  does  not 
interfere  with  any  of  the  older  ones.  His  articles  have  appeared 
in  the  Journal  of  Cancer  Research  during  1919  and  1920.  His 
mutation  theory  agrees  to  some  extent  with  Von  Hansemann's 
anaplasia.  Since  all  biological  units  undergo  mutation  as  a 
phase  of  evolution  he  thinks  the  cancer  cell  is  no  exception.  The 
mutation  theory,  however,  applies  to  all  tumor  cells  and  accounts 
well  for  the  change  of  a  benign  to  a  malignant  tumor.  He 
thinks  heterotopic  rests  may  be  more  inclined  to  mutation  than 
normal  cells,  hence  the  importance  of  heterotopia  in  cancer. 
In  regard  to  cancer  being  a  disease  of  civilisation  this  is  intelli- 
gible because  nearly  all  cancer  nations  represent  much  mixture 
of  blood,  and  animal  experiment  shows  that  pure  strains  are 
much  less  liable  to  cancer  than  mixed  strains.  He  thinks  that 
excess  and  diminution  of  food  articles  in  the  diet  may  start 
mutation  but  only  in  a  secondary  way.     Chronic  irritation  is 

1  Cahen,  Deut.  Zeitschr.f.  Chir.,  1909,  cxix,  p.  415. 

2  Sherrington  and  Copeman,  Brit.  Med.  Jour.,  1910,  ii,  p.  787. 


158  CANCER 

doubtless  the  main  cause  of  mutation,  especially  when  it  dis- 
turbs mitotic  processes.  Of  special  irritants  he  mentions  arsenic, 
tar,  soot  paraffin,  radium  and  x-rays.  Radiation  is  known  to 
determine  altered  mitosis. 

He  is  strong  on  the pre-existence  doctrine,  that  "cancer  exists 
long  before  there  is  any  evidence  of  it."  "  The  cancerous  disease 
is  present  before  the  cancer."  While  this  seems  to  imply  a 
constitutional  origin  the  author  possibly  refers  to  local  pre-exis- 
tence, although  he  nowhere  says  so. 

He  denies  that  there  is  a  "cancer  age,"  and  shows  by  curves 
that  cancer  does  increase  directly  with  age — more  centenarians 
would  have  it  than  nonagenarians,  for  example.  There  is  no 
foundation  for  any  other  teaching.  Under  diet  he  forms  an 
axiom — "a  cell  feeds  but  is  not  fed."  That  is,  it  looks  out  for 
its  own  food  and  cannot  be  forcibly  nourished. 

In  looking  back  over  what  has  been  observed  and  recorded 
in  regard  to  the  excretions,  and  secretions,  including  those  of  the 
ductless  glands,  we  see  that  very  strong  evidence  has  accumu- 
lated to  show  that  they  have  an  intimate  connection  with  the 
development  of  cancer,  as  was  to  be  expected,  since  they  are 
very  important  factors  in  connection  with  metabolism,  upon 
the  proper  performance  of  which ,  in  its  catabolism,  and  anabolism 
cell  life  and  health  depend. 

We  have  also  seen  that  while  there  have  not  been  demon- 
strated any  definite  and  specific  changes  in  the  bio-chemistry 
of  tumors  or  the  blood,  and  no  specific  enzymes,  hormone,  or 
poison  secreted  by  cancer  cells,  which  can  directly  cummunicate 
the  disease  to  another,  there  is  evidence  that  the  disordered 
cells  secrete  a  something  which  deranges  the  blood,  and,  with 
other  causes  related  to  metastasis,  ultimately  tends  to  end  life: 
for  the  blood  in  advancing  cancer  undergoes  very  radical  degen- 
erative changes,  some  of  which  improve  decidedly  when  a 
cancerous  mass  is  removed  surgically,  but  return  with  the  re- 
growth  of  the  tumor. 

We  have  further  seen  that  the  urine  manifests  alterations 


METABOLISM  OF  CANCER  159 

which  indicate  the  trend  of  the  deranged  protein  and  mineral 
metabolism,  and  that  the  saliva  has  an  abnormal  acidity  which 
both  indicates  and  produces  a  disturbed  amylaceous  digestion. 

Lastly  there  is  evidence  that  the  internal  secretions  of  many 
organs,  probably  through  their  influence  on  metabolism,  are 
factors  in  connection  with  the  genesis  and  cure  of  cancer.  Dr. 
Little1  well  says:  "Cancer  is  a  disease  of  disordered  nutrition, 
as  a  result  of  which  cells  revert  to  a  primitive  stage  which  per- 
mits reproduction.  The  disordered  nutrition  is  due  to  relative 
hypofunction  of  the  ductless  glands." 

In  later  chapters  we  shall  consider  the  basic  causes  of  this 
deranged  nutrition,  which,  as  has  been  already  intimated,  has 
much  to  do  with  diet  and  the  various  elements  of  life  which  tend 
to  induce  functional  and  other  derangements  of  the  system, 
many  of  which  are  included  in  and  influenced  by  the  various 
elements  related  to  what  we  term  the  advance  of  civilization. 

1Littlk,  Boston  Med.  Jour.,  1914,  p.  587. 


CHAPTER  XI 
MEDICAL  ASPECTS  OF  CANCER 

In  view  of  all  that  has  preceded,  the  medical  aspects  of 
cancer  loom  very  large  in  comparison  to  the  prevailing  view 
of  its  being  a  local  disease,  which  requires  only  the  surgical 
removal  of  a  tumor;  for  this  latter  in  reality  is  only  the  local 
product  of  an  erroneous  life  process  which  has  existed  with  an 
increasingly  deleterious  force,  for  a  greater  or  shorter  length  of 
time.  In  other  words,  carcinosis,  or  cancer  as  a  disease  has 
existed  long  before  the  local  manifestation  can  be  discovered. 
This  same  constitutional  derangement,  continuing  to  operate, 
unless  checked  by  proper  measures,  accounts  for  the  almost 
constant  recurrence  of  the  neoplasm,  and  for  the  ultimate 
death  from  the  disease,  in  90  per  cent  of  those  who  have  been 
affected  with  cancer. 

In  a  recent  President's  address  before  the  American  Surgical 
Association  Dr.  William  J.  Mayo  spoke  in  regard  to  the  internal 
causation  of  cancer  in  a  manner  which  should  attract  serious 
attention.  Few  have  had  a  wider  acquaintance  with  the  sur- 
gical aspects  of  the  disease  than  he,  and  few  others  know  better 
than  he  how  relatively  impotent  surgical  procedures  are  to  stay 
the  steadily  increasing  mortality  from  cancer.  A  few  of  his 
words  maybe  emoted,  as  they  confirm  so  strongly  the  views  I 
have  held,  and  those  by  which  I  have  practised  for  40  years  and 
more,  with  results  which  I  have  seldom,  if  ever,  have  had  cause 
to  regret.  For,  of  course,  while  there  has  been  a  certain  mor- 
tality, it  has  been  so  much  less  than  that  generally  accepted,  life 
has  been  so  greatly  prolonged  and  patients  have  experienced  so 
very  much  less  pain  than  is  commonly  expected,  that  an  unpre- 
judiced observer  who  had  watched  all  the  cases  could  not  fail  to 
be  satisfied  that  the  right  course  was  being  pursued,  although 

160 


MEDICAL  ASPECTS  OF  CANCER  161 

with  much  yet  to  learn  concerning  the  cure  and  prophylaxis  of 
cancer. 

Speaking  of  the  prophylaxis  of  cancer,  mainly  from  its  surgi- 
cal aspects  in  regard  to  early  operation,  Dr.  Mayo1  says: 
"  Cancer  of  the  stomach  forms  nearly  one-third  of  all  cancers,  of 
the  human  body.  So  far  as  I  know  this  is  not  true  of  the  lower 
animals,  nor  of  uncivilized  man .  .  .  It  is  not  possible,  there- 
fore, that  there  is  something  in  the  habit  of  civilized  man,  in  the 
cooking  or  other  preparation  of  his  food  which  acts  to  produce 
the  pre-cancerous  condition?  .  .  .  Within  the  last  ioo  years 
four  times  as  much  meat  is  taken  as  before  that  time.  If  flesh 
foods  are  not  broken  up,  decomposition  results  and  active 
poisons  are  thrown  into  an  organ  not  intended  for  their  recep- 
tion, and  which  has  not  time  to  adapt  itself  to  the  new  function." 
In  conclusion  he  says:  "Where  cancer  in  the  human  is 
frequent,  a  close  study  of  the  habits  of  civilized  man  as  con- 
trasted with  primitive  races  and  lower  animals,  where  similar 
lesions  are  conspicuously  rare,  may  be  of  value,"  and  finally, 
"the  prophylaxis  depends,  first,  on  a  change  in  these  cancer 
producing  habits,  and,  second,  on  the  early  removal  of  all 
pre-cancerous  lesions  and  sources  of  chronic  irritation." 

It  is  strange  that  the  medical  profession  has  been  so  slow  in 
accepting,  or  unwilling  to  accept  and  act  upon  the  suggestions 
along  this  line  which  have  been  thrown  out  from  time  to  time, 
for  very  many  years,  a  hundred  and  more,  by  surgeons  of 
prominence  well  acquainted  with  cancer,  and  who  felt  their 
inability  to  cope  with  this  distressing  and  fatal  disease. 

That  all  may  know  that  Dr.  Mayo  is  not  alone  in  his  impres- 
sion that  "there  is  something  in  the  habits  of  civilized  man 
.  .  .  which  acts  to  produce  the  pre-cancerous  condition," 
I  must  briefly  refer  to  some  of  the  leading  surgeons  of  the  past, 
who,  from  time  to  time,  with  more  or  less  emphasis,  have 
claimed  that  the  disease  is  constitutional,  and  that  it  depends 
largely  on  diet  and  mode  of  life:  later  I  shall  hope  to  present 
sound  grounds  for  such  belief. 

1  Mayo,  Annals  of  Surgery,  June,  1914,  p.  805. 
11 


162  CANCER 

Abernethy,  the  great  English  surgeon,  who  wrote  in  1816,  has 
already  been  referred  to  in  a  previous  chapter,  as  saying: 
"The  best  timed  and  best  conducted  operation  brings  with  it 
nothing  but  disgrace,  if  the  diseased  propensities  of  the  consti- 
tution are  active  and  powerful,"  saying  that  "after  an  operation 
we  are  most  particularly  incited  to  regulate  the  constitution, 
lest  the  disease  should  be  revived  or  renewed  by  its  disturbance." 

Walshe,  in  181 5,  in  his  classical  work  on  cancer,  gives 
numerous  references  to  the  constitutional  nature  of  cancer, 
original  or  quoted  from  recognized  authorities,  as  well  as 
expressions  in  regard  to  the  futility  of  expecting  that  surgical 
interference  could  cure  the  real  disease  in  any  great  proportion 
of  cases.  He  says:  "It  would  in  theory  appear  that  the 
removal  of  a  tumor  cannot  in  itself  cure  the  disease,  as  the  local 
formation  is  but  a  symptom  of  the  general  vice  of  the  economy. 
.  .  .  This  tissue  being,  as  the  normal  textures,  the  seat  of 
nutrition,  is,  like  them  susceptible  of  its  disordered  actions." 
He  even  quotes  Galen  as  holding  this  view.  He  also  mentions 
the  effect  of  diet  on  the  disease. 

Lambe,  in  181 5,  wrote  clearly  in  regard  to  the  causation  of 
cancer  from  luxurious  living,  and  adduced  strong  proof  to 
show  the  effect  of  diet  in  curing  cases  of  undoubted  cancer  of 
the  breast  and  uterus,  the  diagnosis  of  which  had  been  con- 
firmed by  prominent  surgeons  of  the  day,  several  of  whom 
endorsed  the  vegetarian  diet. 

Sir  Astley  Cooper,  in  1825,  said:  "The  cause  of  the  disease 
(cancer  of  the  breast)  is  supposed  to  be  some  accidental  blow 
or  the  pressure  of  a  part  of  the  dress:  but  although  a  blow  may 
produce  a  swelling  on  the  bosom,  yet  that  swelling  will  not  be  of 
a  scirrhous  nature  unless  some  defective  state  of  the  constitu- 
tion disposes  to  malignant  action.  If  the  constitution  be 
good  the  effects  of  the  blow  are  speedily  dissipated:  but  if  the 
constitution  be  faulty,  the  swelling  grows  into  a  formidable 
disease." 

Sir  James  Paget,  that  prince  of  surgeons  and  pathologists,  in 
1854,  comes  out  very  strongly  for  the  constitutional  origin  of 


MEDICAL  ASPECTS  OF  CANCER  163 

cancer,  when  he  says  twice  in  his  "Lectures  on  Surgical  Patho- 
logy/' that  cancers  are:  "local  manifestations  of  certain 
specific  morbid  states  of  the  blood:"  and  again  he  says:  "I 
believe  it  to  be  constitutional,  in  the  sense  of  having  its  origin 
and  chief  support  in  the  blood  ...  the  existence  of  the  morbid 
material  in  the  blood,  whether  in  the  rudimental  or  effective 
state,  constitutes  the  general  predisposition  to  cancer." 

The  late  Dr.  Willard  Parker,  one  of  New  York's  great 
surgeons,  in  a  study  of  397  cases  of  cancer  of  the  breast,  observed 
from  1830  to  1880,  wrote  very  strongly  in  regard  to  the  con- 
stitutional relations  of  cancer.  In  considering  its  etiology  he 
places  first,  luxurious  living  and  particularly  excess  in  animal 
food.  He  says:  "Cancer  is  to  a  great  degree  one  of  the  final 
results  of  a  long-continued  course  of  error  in  diet,  and  a  strict 
dietetic  regimen  is,  therefore,  the  chief  factor  in  the  treatment, 
preventative  and  curative."  He  further  says:  "In  regard  to 
the  effect  of  abstemiousness  on  cancer  I  can  speak  with  great 
positiveness,  that  a  vegetable,  or  at  least  a  very  bland  diet, 
does  check  the  progress  of  the  disease,  and  in  some  cases,  now 
under  treatment,  has  been  attended  by  an  alleviation  of  symp- 
toms; and  in  a  few  instances  even  by  a  recession  of  the  growth. " 

If  it  were  necessary,  any  amount  of  further  corroborative 
evidence  could  be  presented,  collected  from  old  and  recent 
literature,  giving  the  experience  and  views  of  practical  men  who 
have  observed  and  studied  cancer  and  know  of  what  they 
speak.  Often  these  are  fugitive  observations,  like  those  of 
Dr.  Mayo,  others  have  written  largely  on  the  subject,  often  in 
complete  journal  articles  and  also  in  number  of  books,  such  as 
those  of  Forbes  Ross  and  Robert  Bell,  already  alluded  to. 
Some  of  these  have  often  presented  quite  opposite  views  as 
to  the  real  cause  and  nature  of  the  systemic  disturbances 
leading  up  to  cancer,  and  their  remedy,  all,  however,  agree  as 
to  there  being  a  basic  constitutional  origin  of  the  disease. 
Moreover,  the  trend  of  all  is  to  establish  very  firmly  the  thesis 
that  cancer  is  no  longer  to  be  looked  upon  as  a  purely  local 
affection,  of  unknown  cause,  but  that  it  is  the  final  result  of  a 


I 64  CANCER 

disturbance  of  equilibrium  in  the  system,  generally  of  long 
continuance.  This  induces  certain  cells,  first  in  some  particular 
locality,  to  take  on  an  abnormal,  vicious  action,  which  is  per- 
petuated by  the  continuance  of  the  same  systemic  condition 
which  induced  the  first  aberration  from  a  normal  state  of  life 
and  function. 

But  these  many  fugitive  and  other  observations  and  studies 
have  never  attracted  the  attention  they  deserve,  and  it  would 
sometimes  seem  as  if  they  were  deliberately  ignored,  and  that 
scientists  and  practitioners  had  combined  to  recognize  only  the 
local  nature  and  treatment  of  cancer.  The  truth  is  that  very 
little  serious  effort  has  ever  before  been  made  to  assemble  all 
the  evidence  of  the  constitutional  nature  of  the  disease,  and 
by  synthesis  and  deduction  to  establish  a  basis  for  the  recogni- 
tion and  proper  treatment  of  the  constitutional  elements 
involved  in  the  ultimate  causation,  continuance,  increase,  and 
recurrence  of  the  cancer  lesion. 

The  glamor  of  surgery  during  "$he  last  two  decades,  has 
excluded  from  the  minds  of  the  medical  profession  and  laity 
much  thought  of  the  medical  aspects  and  treatment  of  cancer; 
and  the  reasons  are  not  difficult  to  discover. 

Under  previous  medical  care,  with  no  sound  reason  advanced, 
and  with  no  definite  plan  of  treatment  elaborated,  these  cases 
had  commonly  been  seen  to  go  from  bad  to  worse,  until  the 
disease  was  considered  incurable,  and  the  patient  was  then  left 
to  die  under  morphia,  which  only  increased  the  disease,  by 
further  deranging  the  secretions  and  excretions.  As  the  local 
manifestation  of  the  disease  appeared  to  be  the  real  seat  of  the 
trouble  from  which  it  spread  through  adjoining  glands,  which 
could  be  recognized,  it  was  very  natural  that  the  surgeons 
believed  that  by  removing  the  offending  tumor  early  the  malady 
could  be  checked,  and  soon  they  learned,  or  thought  they  did, 
that  by  also  extirpating  the  neighboring  enlarged  glands  the 
work  would  be  effective.  But  they  forgot  or  did  not  know 
that  elements  of  the  disease  lingered  in  the  deeper  lymphatic 
vessels  and  glands,  which  were  not  removable. 


MEDICAL  ASPECTS  OF  CANCER  165 

Then,  the  immediate  results  of  well  conducted  surgical 
operations  often  seemed  to  be  favorable,  for  at  time  at  least, 
with  the  possible  expectation  that  with  a  recurrence  of  the 
malady  there  was  still  hope  that  further  operations  might 
succeed  in  eradicating  the  disease.  But  we  have  already  quoted 
Ewing,  from  the  observation  and  view  of  a  scientific  student  of 
very  wide  experience,  in  saying  that  he  believed  that  secondary 
operations  on  cancer  only  shortened  life,  and  we  know  that 
after  them  the  pain  and  distress  of  recurrent  lesions  are  excessive, 
and  the  case  generally  hopeless.  However,  for  the  last  two 
decades  surgery  has  had  full  sway,  and  the  medical  man  has 
practically  kept  his  hands  off  from  cancer  and  referred  these 
cases  at  once  to  the  surgeon,  with  the  result  often  mentioned 
that  90  per  cent  of  those  once  affected  die  of  the  disease, 
unless  carried  off  otherwise.  Whereas  by  the  practice  of  great 
patience  and  acumen  the  mortality  of  tuberculosis  has  been 
reduced  nearly  30  per  cent  since  1900,  and  that  of  cancer  has 
advanced  by  almost  the  same  percentage.  It  is  certainly 
time  for  the  medical  man,  in  view  of  what  has  preceded  and  will 
follow,  to  see  if  great  patience  and  similar  acumen  will  not 
enable  him  to  check  this  constantly  rising  mortality,  and  effect 
something  commensurate  with  what  has  been  accomplished 
in  tuberculosis. 

On  the  Mortality  chart  furnished  each  year  by  the  United 
States  authorities,  there  are  several  other  chronic  diseases,  whose 
steadily  rising  mortality  during  the  last  twenty  years  may  well 
excite  the  alarm  of  the  medical  profession,  and  incite  it  to 
more  intelligent  and  earnest  efforts  to  control  their  morbi- 
dity and  mortality.  These  are  heart  disease,  kidney  disease, 
and  apoplexy.  The  deaths  from  the  first  of  these — heart 
disease — now  exceed  those  from  tuberculosis,  having  risen 
from  128. 1  persons  per  100,000,  to  197.7,  the  others  having 
risen  also  about  15  and  25  per  cent.  All  these  three  are  recog- 
nized as  having  much  to  do  with  diet  and  mode  of  living,  and 
it  is  reasonable  to  suppose  that  cancer,  whose  advancing 
mortality  has  outstripped  that  of  these  three,  should  be  of 


166  CANCER 

somewhat  the  same  general  cause.  The  dietary,  hygenic, 
and  medical  treatment  suitable  for  the  latter  should  also  avail 
towards    the    prophylaxis    of    these    three    serious    affections. 

There  could  hardly  be  a  more  eloquent  argument  for  the 
application  of  medical  perspicacity  and  acumen  to  the  study 
and  treatment  of  cancer  than  the  results  of  the  same  which  have 
been  applied  to  tuberculosis  with  such  wonderful  results. 
Because  science  and  clinical  study  have  not  been  able  thus 
far  to  point  to  the  single  cause  of  cancer,  to  discover  a  single 
remedy,  or  to  lay  out  a  treatment  which  will  always  be  success- 
ful, there  is  no  reason  for  doubting  that  we  are  on  the  right 
track,  when  every  sign  points  that  way. 

Nor  is  there  any  wisdom,  or  sagacity,  but  only  mis-conception, 
error,  and  obstinacy,  in  questioning  the  correctness  of  the 
medical  aspect  of  cancer  simply  because  we  are  constrained  to 
accept  and  acknowledge  that  there  are  other  elements  which 
may  act  as  coadjutors  in  producing  the  local  lesions  of  the 
disease.  We  have  always  been  taught  that  there  are  primary 
and  also  secondary,  or  exciting,  causes  of  many  affections,  and  we 
have  seen  in  previous  chapters  that  various  causes  of  irritation 
may  be,  and  are,  the  exciting  cause  of  the  local  development 
of  the  neoplasm  in  any  particular  region.  Thus,  no  one 
doubts  that  a  jagged  tooth  induces  a  cancer  on  the  tongue, 
a  smoker's  pipe  may  be  responsible  for  cancer  of  the  lip,  betel 
nut  chewing  causes  cancer  of  the  mouth,  a  blow  on  the  breast 
may  be  followed  by  a  cancer,  retained  gall  stones  or  irritating 
feces  may  be  the  exciting  cause  of  cancer  of  the  gall  bladder 
and  intestine,  many  sarcomas  undoubtedly  owe  their  origin  to 
a  single  blow  on  a  bony  structure,  etc.  But  how  often  do  these 
accidents,  if  we  may  so  call  them,  occur  without  any  such 
result  following,  and  how  continually  are  there  injuries  of  all 
sorts,  and  even  prolonged  irritating  agencies  acting  without 
cancer  resulting. 

A  remarkable  confirmation  of  the  fact  that  cancer  is  not  solely 
the  result  of  traumatism  is  found  in  the  extreme  rarity  of  the 
disease  on  the  extremities,  which  are  so  often  injured,  or  after 


MEDICAL  ASPECTS  OF  CANCER  167 

the  damage  to  tissues  caused  by  surgical  operations  in  general : 
and  also  that  carcinoma  is  unknown  as  the  result  of  skin  graft- 
ing, although  it  is  these  same  epidemic  elements  which  are  the 
original  seat  of  the  disease. 

There  must,  therefore,  be  some  occult,  if  you  please,  process 
going  on  in  the  system,  which  lays  the  foundation,  so  to  speak, 
for  the  morbid  response  of  the  cells  to  such  irritants,  something 
which  so  alters  their  nutrition  that  disturbance  of  their  integrity 
results,  and  instead  of  pursuing  their  normal  course  of  homol- 
ogous reproduction,  or  fulfilling  their  secretory  powers,  they 
take  on  a  new,  heterologous  formation  and  begin  a  wild,  unre- 
strained, and  destructive  course,  with  the  well  known  results. 
This  primary  or  basic  cause  is  found  in  the  disordered  nutri- 
ment which  they  receive  through  blood  which  has  been  deranged 
in  various  ways  and  by  various  causes.  In  several  chapters 
some  of  the  causes  leading  to  these  derangements  are  pointed 
out. 

Even  in  regard  to  the  possible  influence  of  the  endocrinous 
glands  the  same  argument  holds  good.  Namely,  that  those 
organs  not  receiving  the  exactly  proper  pabulum,  or  blood 
supply,  either  fail  in  their  activity  or  produce  an  inadequate 
or  improper  secretion,  incapable  of  effecting  the  correct 
interchange  of  tissue  elements,  represented  by  metabolism. 

The  effect  of  diet  will  be  considered  later  in  another  chapter, 
but  a  word  may  be  said  with  advantage  here.  As  all  cells  are 
formed  and  nourished  rightly  or  wrongly,  by  what  goes  into 
the  mouth,  there  can  be  no  question  but  that  diet  must  be  of 
supreme  importance  in  connection  with  cancer,  and  this, 
indeed,  is  the  first  or  basic  element  to  be  considered  in  its 
treatment,  without  this  being  correct  cancer  is  a  hopeless  disease. 


CHArTER  XII 
NOSOLOGY  AND  RELATIONS  OF  CANCER 

The  only  method  by  which  we  can  comprehend  the  nature 
of  cancer  is  by  a  system  of  comparing  its  phenomena  with 
those  of  other  processes,  not  only  pathological  but  normal. 
In  this  way  we  can  form  an  idea  not  only  as  to  what  cancer 
is  but  what  it  is  not. 

Normal  Growth  and  Development. — The  energy  of  growth 
of  a  malignant  disease  has  often  been  compared  to  that  of  the 
embryo,  and  it  is  stated  that  in  the  natural  process  of  growth 
this  energy  is  superior  to  that  in  the  malignant;  inasmuch  as 
the  embryo  starting  from  a  single  ovum,  the  weight  of  which 
can  be  computed,  increases  its  weight  more  rapidly  than  a  tumor, 
concerning  the  beginnings  of  which  we  know  nothing.  Further- 
more in  a  fetus,  in  the  embryonal  stage,  processes  like  infil- 
tration of  connective  tissue  by  epithelium  may  be  seen  to 
occur,  exactly  as  in  cancer,  although  this  is  only  temporary. 

To  turn  to  another  chapter  in  embryology  there  is  a  strong 
resemblance  between  the  growth  of  cancer  and  that  of  the 
trophoblastic  tissue  which  nourishes  the  embryo  at  its  earliest 
stages.  At  a  later  period,  after  the  formation  of  the  chorion, 
the  syncytial  cells  exhibit  properties  which  in  many  ways 
resemble  cancer  cells.  These  decidual  cells  will  be  discussed 
under  chorio-epithelioma.  It  is  enough  to  state  here  that  both 
embryonal  and  fetal  tissues  behave  to  some  extent  like  car- 
cinoma, so  that  the  latter  cannot  be  regarded  as  anything 
absolutely  foreign  to  the  economy.  While  cancer  proper  is 
distantly  related  to  these  processes,  numerous  malignant, 
non-cancerous  growths  are  much  more  closely  related,  and 
this  is  the  germ  of  the  idea  that  cancer  is  something  added  to 
to  the  simpler  and  more  primitive  types  of  malignancy.  The 
latter  are  rare  and  show  no  tendency  to  increased  incidence; 

168 


NOSOLOGY  AND  RELATIONS  OF  CANCER  169 

they  are  local  and  not  constitutional,  surgical  and  not  medical. 
Cancer  is  an  entity  of  which  malignancy  is  a  pronounced 
attribute,  but  it  is  something  more. 

Epithelium  in  its  Normal  and  Pathological  Expressions. — 
Cancer  is  an  epithelial  formation  and  it  is  necessary  to  compare 
it  with  both  normal  and  pathological  growth.  Epithelium  of 
the  skin,  mucosae,  and  glandular  organs  is  in  constant  change; 
it  is  being  shed  and  renewed  continually.  Save  for  the  blood 
corpuscules  there  is  no  other  tissue  in  the  body  in  which  this 
rotation  is  clearly  in  evidence.  Differences  between  cancerous 
and  ordinary  epithelial  cells  have  already  been  mentioned, 
including  the  fact  that  cancer  tissue  of  certain  animals  can  be 
implanted  and  form  tumors  of  its  own  kind  in  suitable  soil  in 
animals  of  the  same  class;  but  while  epithelial  reproduction  is 
seen  in  human  skin-grafting,  tumor  formation  does  not  take 
place.  The  cancer  cells  awaken  some  reaction  in  strange 
tissues,  so  that  a  stroma  with  blood  vessels  is  formed  to  nourish 
the  new  growth.  This  desmoplastic  function  is  one  of  the 
most  striking  attributes  of  the  cancer  cell,  but  as  will  appear 
later,  it  also  resides  in  non-cancerous  epithelium.  Thus  cancer 
is  often  antedated  by  the  formation  of  the  two  leading  forms  of 
benign  epithelial  tumor,  papilloma  and  adenoma.  These  are 
a  connecting  link  between  hyper-plastic  and  neoplastic  pro- 
cesses, and  represent  an  outgrowth  of  epithelium.  They  are 
peculiar  in  that  they  form  no  true  stroma,  being  nourished  from 
the  subjacent  corium  and  submucous  elements.  Papillomata  are 
plainly  due,  for  the  most  part,  to  some  form  of  local  irritation,  and 
the  agencies  which  cause  their  appearance  also  cause  cancer. 
In  a  certain  per  cent  of  cases  they  are  changed  to  malignant 
tumors,  or  else  malignancy  pre-exists  in  a  certain  number. 
Adenomata,  on  the  other  hand,  represent  an  ingrowth  of 
epithelium  into  the  sub-epithelium,  and  presumably  are  of 
heterotopic  origin,  in  part.  The  epithelium  in  ordinary 
adenoma  is  desmoplastic,  and  a  considerable  stroma  may  be 
formed.  As  in  the  case  of  papilloma  there  is  a  tendency  to 
develop  into  cancer. 


170  CANCER 

An  interesting  feature  of  papilloma  is  the  tendency  to  recur 
after  extirpation.  This  property  then  is  not  primarily  can- 
cerous but  resides  in  the  epithelium  of  the  benign  growth. 
But  it  is  not  so  easy  to  make  straightway  a  difference 
between  papilloma  and  epithelioma.  Some  adenomata  result 
from  irritation,  while  not  all  papillomata  have  self-evident 
causes.  The  two  forms  must  often  co-exist  clinically.  We 
see  papilloma  develop  in  the  cystic  cavity  of  certain  ad- 
enomas; and  for  a  papilloma  to  become  highly  malignant 
there  must  be  an  ingrowth  of  epithelium  into  the  sub-epithelial 
structure. 

By  using  certain  agents  which  stain  epithelium,  it  has  been 
possible  to  cause,  in  laboratory  animals,  epithelial  neoplasms 
which  are  not  cancerous. 

If  epithelium  per  se  had  any  tendency  to  become  cancerous 
without  any  other  component  it  should  appear  in  wound  healing 
in  the  elderly.  But  in  all  processes  of  repair  it  is  very  excep- 
tional, even  in  the  aged  for  the  scar  of  an  ordinary  wound  to 
develop  cancer,  and  perhaps  only  in  patients  with  the  peculiar 
condition  of  metabolism  pre-disposing  thereto. 

Transitional  forms  between  adenoma  and  cancer  are  well 
known;  in  malignant  adenoma,  so-called,  there  may  be  no  imme- 
diate change  in  anatomical  structure.  The  growth  rate  may  be 
very  rapid  so  that  the  basement  membrane  may  be  defective 
or  absent,  yet  this  need  not  amount  to  malignancy.  It  is 
known  that  in  malignant  adenoma  the  epithelium  may  force 
itself  through  a  basement  membrane.  In  adeno-carcinoma, 
so-called, the  original  structure  of  the  adenoma  maybe  recogniz- 
able, not  because  of  residual  tissue  but  because  the  newly 
formed  cells  make  an  abortive  attempt  to  form  an  organoid 
tumor.  In  these  cases  the  stroma  and  even  a  lumen  suggesting 
a  normal  gland  may  be  formed,  but  there  is  never  a  new  formed 
basement  membrane.  Adenoma  changing  to  cancer  is  evidently 
quite  distinct  from  a  primary  adeno-carcinoma,  which  is  better 
termed  a  cylindroma  or  columnar  cell  cancer,  to  avoid  this 
source  of  confusion. 


NOSOLOGY  AND  RELATIONS  OF  CANCER  1 7 1 

Benign  Tumors. — Having  entered  a  little  pcrmaturely  into 
the  consideration  of  epithelial  tumors,  we  may  in  passing  allude 
to  tumors  as  a  whole,  without  reference  to  the  malignant  com- 
ponent. It  may  be  said  of  them  as  a  class  that  they  contain 
wholly  normal  tissue  in  a  large  minority.  Grown  in  vitro  there 
is  little  difference  in  the  character  of  the  cells,  whether  these 
proceed  from  benign  or  malignant  growths.  All  tumors  are 
autonomous  and  autocratic,  and  not  amenable  to  the  ordinary 
laws  of  growth,  development,  and  repair.  A  tumor  is  less 
organized  than  normal  tissues,  and  the  less  the  degree  of  organi- 
zation the  greater  the  tendency  to  malignancy.  There  is  a 
radical  difference  in  the  plan  of  growth,  for  a  benign  tumor  ex- 
pands from  within  like  an  onion,  without  any  effort  to  infiltrate 
the  evironment,  while  a  malignant  growth  grows  from  the  peri- 
phery and  infiltrates  outlying  tissues.  It  has  often  been  shown 
that  benign  growths,  taken  en  masse,  exhibit  all  the  phenomena 
of  so-called  malignancy;  although  the  individual  neo-plasm  may 
be  either  one  or  the  other.  If  we  take  all  tumors  in  common 
the  only  causal  factor  common  to  all  alike  is  irritation  or  injury. 

As  already  intimated  a  tumor  is  autonomous  and  independent 
of  laws  which  regulate  the  individual.  If  the  subject  starve, 
the  growth  is  not  inhibited;  but  lest  the  idea  of  autonomy  be 
carried  too  far  it  is  well  to  remember  that  if  the  subject  dies  the 
tumor  dies  at  once.  The  subject's  hair  may  perhaps  grow  after 
death  but  not  his  tumor. 

Of  other  facts  to  notice,  one  is  that  in  neoplastic  growth  of 
glandular  tissue,  ducts  are  never  formed.  Tumors  never  de- 
velop a  special  nerve  supply  although  they  must  be  under  the 
influence  of  vasomotor  nerves.  Their  blood  supply  is  in  general 
poor,  outside  of  certain  angiomata. 

To  state  that  tumor  cells  are  embryonic  is  an  error,  for  by  an 
embryonic  cell  we  understand  one  which  can  develop  into  some- 
thing higher. 

Inflammation. — The  relations  between  cancer  and  ordinary 
inflammation  are  numerous  and  varied.  Cancer  invasion  seems 
able  to  set  up  inflammation  in  connection  with  certain  stroma 


172  CANCER 

formation,  so  that  here  the  neoplasm  figures  as  the  cause  of  a 
fibro-plastic  process.  On  the  other  hand,  chronic  inflammation 
seems  to  be  a  common  cause  of  cancer;  in  mammary  cancer,  for 
example,  it  is  claimed  at  the  Mayo  clinic  that  a  previous  chronic 
mastitis  is  the  essential  forerunner  of  cancer  of  the  breast.  In 
many  cancers  there  seems  to  be  an  inflammatory  component 
from  the  clinical  standpoint;  for  the  application  of  a  soothing 
and  antiphlogistic  regimen  will  cause  a  prompt  disappearance 
of  some  of  the  more  distressing  symptoms.  A  sarcoma  may 
exceptionally  start  up  a  zone  of  peripheral  inflammation,  while 
conversely  in  the  intense  connective  tissue  reaction  about  a  can- 
cerous growth,  sarcoma  has  been  known  to  develop.  In  the 
most  acute  known  types  of  cancer  it  is  almost  impossible  to  state 
where  inflammation  begins  and  malignancy  leaves  off.  Large 
sarcomatous  tumors  are  hot  to  the  touch.  Pre-cancerous 
lesions  are  very  largely  chronic  inflammations.  Leucoplakia  is 
technically  a  superficial  glossitis.  Many  skin  cancers  develop 
upon  a  basis  of  chronic  dermatitis,  and  in  general  any  irritant 
which  can  set  up  a  dermatitis,  with  secondary  hyperkeratosis, 
should  be  able  to  cause  an  epithelioma.  Myeloma  or  giant, 
cell  sarcoma,  formerly  so-called,  is  now  recognized  as  a  chronic 
osteitis.  Numerous  growths  which  clinically  are  sarcoma  are 
in  reality  granulomata  and  probably  of  infectious  origin.  The 
numerous  types  of  lymph-node  tumors  and  so-called  leucomas 
stand,  like  certain  sarcomas,  midway  between  neoplasms  and 
infections. 

Keratoses. — Cancer  has  numerous  points  of  contact  with  the 
hyper-  and  parakeratoses.  The  disease  psoriasis,  which  is 
histologically  an  invasion  of  the  corium  by  the  epithelial  cells 
with  accompanying  elongation  of  the  papillae,  has  several 
curious  analogies  with  cancer.  It  affects  the  healthiest  of 
subjects  as  well  as  others,  and  has  an  irresistible  tendency  to 
reappear  after  recession  due  to  treatment.  It  cannot  be  cured 
by  local  or  internal  treatment,  but  on  a  vegetarian  diet,  plus  a 
sort  of  physical  training,  it  may  be  held  in  check.  It  is  claimed 
that  psoriatic  athletes  are    often  free  from    eruption  during 


NOSOLOGY  AND  RELATIONS  OF  CANCER  173 

active  training,  but  the  lesions  reappear  when  training  stops. 
But  psoriasis  is  seldom  a  precursor  of  cancer.  The  condition 
known  as  acanthosis  nigricans,  a  rare  form  of  skin  disease,  may- 
be secondary  to  or  at  least  associated  with  visceral  cancer,  the 
nature  of  this  association  being  quite  obscure.  In  arsenical 
tylosis,  so-called,  which  develops  in  certain  subjects  under 
the  continued  administration  of  arsenic,  epithelioma  occa- 
sionally develops,  despite  the  old  belief  that  arsenic  is  a 
preventive  of  cancer.  The  relations  of  senile  keratosis  to  epithe- 
lioma are  well  known.  This  does  not  exhaust  the  list,  for  in 
dermatitis  due  to  the  irritation  of  paraffin,  etc.,  a  hyperkera- 
tosis precedes  the  development  of  cancer.  Histologically  the 
resemblance  between  a  common  corn  or  a  wart  and  an  epithelio- 
ma is  so  striking,  that  failure  of  the  latter  to  develop  in  these 
familiar  affections  is  puzzling.  A  few  such  cases  are  on  record, 
but  when  we  consider  the  universality  of  corns  and  warts,  we  are 
forced  to  believe  that  the  fingers  and  toes  are  almost  immune 
to  cancer  from  irritation. 

Sarcoma. — The  points  of  dissimilarity  between  cancer  and 
sarcoma  are  numerous  and  often  striking.  While  they  share 
the  essential  features  of  malignancy,  cancer  is  far  more  common 
and  greatly  on  the  increase,  while  sarcoma  makes  up  but  2  or  3 
per  cent  of  all  tumors,  and  is  not  known  to  be  increasing  greatly. 
No  one  has  ever  claimed  that  sarcoma  is  a  constitutional  or 
diathetic  affection,  but  among  those  who  make  this  claim  for 
cancer  are  the  editors  of  the  "Index  Medicus,"  who  have 
always  classed  cancer  among  metabolic  and  diathetic  diseases; 
while  sarcoma  is  placed  under  tumors,  hence  is  made  a  surgical 
affection.  Sarcoma  is  much  more  apt  to  occur  before  40,  and 
cancer  after  40.  Multiple  primary  sarcoma  is  not  uncommon, 
while  multiple  primary  cancer  is  almost  a  curiosity.  Cancer 
has  more  stroma  than  sarcoma  and  is  often  organoid  in  charac- 
ter, while  sarcoma  is  poor  in  stroma  and  mostly  histioid. 
Cancer  manufactures  its  stroma  from  the  connective  tissues 
which  it  invades,  while  sarcoma  is  said  to  form  its  stroma 
from  its  own  cells.     Early  sarcoma  may  show  no  tendency  to 


174  CANCER 

invade  the  surrounding  tissues  while  cancer  invades  from  the 
very  outset.  Sarcoma  is  more  apt  to  metastasize  by  the  blood 
route,  and  cancer  by  the  lymphatics. 

The  two  growths  attack  by  preference  different  structures: 
with  sarcoma  it  is  the  bones  and  periosteum,  fascias,  ligaments, 
and  tendons,  and  next  to  these  the  brain,  gonads,  and  skin. 
With  cancer  it  is  the  female  breast  and  uterus,  the  stomach  and 
colon,  the  mouth  and  skin.  Thus  the  latter  is  the  only  struc- 
ture in  which  both  affections  occur  in  numbers,  but  cutaneous 
cancers  are  to  some  extent  a  special  type  which  differs  from  the 
true  cancers  in  a  number  of  ways.  Both  affections,  primary 
cancer  and  sarcoma,  are  rare  in  the  liver  and  intestines,  and 
muscles.  Each  is  rare  in  structures  in  which  the  other  is 
common.  Cancer  seems  able  to  provoke  the  formation  of 
sarcoma  in  rare  cases,  through  the  intense  connective  tissue 
reaction;  while  sarcoma  is  not  known  to  produce  carcinoma. 
When  serially  transplanted  in  the  laboratory,  mouse  cancer 
has  eventually  resulted  in  sarcoma,  but  the  opposite  has  not 
been  noted. 

Cancer  often  causes  the  tissues  around  it  to  put  up  a  defense 
reaction,  but  such  behavior  is  much  less  in  evidence  in  sarcoma. 
Sarcoma  follows  at  times  upon  a  pronounced  injury,  like  a  blow; 
this  is  rarely  seen  in  cancer,  if  at  all  only  in  the  breast.  Cancer 
habitually  follows  chronic  irritation,  while  sarcoma  does  not 
exhibit  such  behavior.  Sarcoma  shades  into  conditions  like 
lymphoma  and  leucoma,  and  granulation  tumors,  while  cancer 
shows  no  such  affiliations.  Sarcoma  naturally  agrees  histo- 
logically with  the  tissues  that  develop  from  the  mesoblast, 
while  cancer,  developing  from  the  epi-  and  hypo-blast,  is  akin 
to  the  benign  epithelial  growths.  Sarcoma,  while  even  more 
malignant  than  cancer,  is  yet  often  amenable  go  relatively  mild 
measures  of  treatment,  such  as  Coley's  toxins  and  exsection  of 
the  large  arterial  trunk  which  supplies  it;  it  is  also  more  amen- 
able to  radiation  therapy  than  most  cancer.  Cancer  causes  the 
cachexia  which  bears  its  name,  while  in  sarcoma  it  is  said  that 
only  a  high   degree  of  anemia   results.     The  rarer  forms  of 


NOSOLOGY  AND  RELATIONS  OF  CANCER  175 

malignancy  like  chorio-epithelioma,  hypher-nephroma,  endothe- 
lioma, are  more  like  sarcoma  than  cancer.  In  teratoma  both 
tissues  may  be  seen  side  by  side.  The  position  of  melanoma — 
whether  cancer  or  sarcoma — is  not  yet  settled. 

Chorio-epithelioma. — By  this  term  two  separate  affections  are 
understood,  of  which  one  develops  in  connection  with  child- 
birth, the  other  is  associated  with  teratomata.  The  decidual 
cell,  to  begin  with,  shows  certain  properties  not  seen  in  the  cancer 
cell.  In  normal  pregnancy  it  infiltrates  the  uterus  like  a 
malignant  growth,  and  even  enters  the  blood-vessels  and  may 
be  arrested  in  the  pulmonary  capillaries,  without  causing 
metastases.  Pathologically  the  same  cell,  without  apparent 
cause,  multiplies  into  a  vesicular  mole,  and  with  or  without 
this  step  the  chorionic  cells,  which  persist  in  the  uterus  after 
abortion  or  labor,  may  become  malignant  and  cause  early 
metastases  in  the  lungs.  The  latter  may  result  even  in  the 
absence  of  a  primary  focus  in  the  uterus.  Yet  despite  its  high 
malignancy  it  is  evident  that  chorio-epithelioma  has  a  greater 
tendency  towards  regression  than  any  other  malignant  growth. 
The  only  explanation  of  all  these  facts  is  the  presence  or  absence 
of  some  antibody  which  holds  the  decidual  cell  in  check.  In 
pregnancy  the  woman  seems  in  no  danger,  but  only  afterwards, 
although  the  risk  is  not  great.  This  affection  occurs  only  after 
conception,  according  to  standard  writers,  but  cases  occur 
very  rarely  in  which  previous  conception  has  not  been 
shown. 

Ordinary  cancer  of  the  corpus  uteri  differs  radically  from 
chorio-epithelioma.  The  former  is  fairly  common,  occurs  in 
elderly  women  who  have  never  borne  any,  or  have  borne  but  one 
child,  and  is  much  less  malignant  than  the  average  cancer; 
chorio-epithelioma  occurs  in  comparatively  young  women  who 
have  borne  children  rapidly.  Cancer  metastasizes  slowly 
and  by  the  regional  lymphatics,  while  the  other  growth  metas- 
tasizes early  and  by  the  blood  route.  There  is  no  better 
demonstration  that  chorio-epithelioma  is  not  a  form  of  cancer. 
There  are  other  dissimilarities,  for  chorio-epithelioma  stands  in 


1 76  CANCER 

some  relation  to  the  ovary,  the  amount  of  lutein  material 
being  augmented;  but  whether  this  is  cause  or  effect  is  not  yet 
known. 

Malignant  Teratomata  and  Cancer. — Teratomata  are  always 
congenital  and  undoubtedly  originate  from  misplaced  embry- 
onal cells,  while  cancer  has  this  origin  only  in  a  small  per  cent, 
as  far  as  is  known.  The  cells  from  which  teratomata  develop 
apparently  do  not  come  from  the  individual  proper  but  either 
from  the  trophoblast,  which  is  of  fetal  origin,  or  from  a  so-called 
autosite  or  remains  of  a  unioval  twin  birth.  The  malignant 
element  of  a  teratoma  is  indistinguishable  from  ordinary 
chorio-epitheliomav  this,  too,  originating  in  fetal  tissues. 

Teratoma,  unlike  cancer,  differs  from  the  tissues  in  which  it 
originates,  and  the  functions  of  the  parent  cell  are  handed  down 
in  a  much  higher  degree  than  in  cancer.  The  malignant  tumors 
of  the  endocrine  organs  which  cause  the  formation  of  hormones, 
and  the  results  of  their  physiological  action  are  largely  tera- 
tomata. The  metastases  of  a  teratoma  are  cherioepithe- 
liomatous.  Cancer  can  never  be  produced  experimentally 
from  embryonal  tissues,  but  inoculation  of  the  latter  readily 
produces  teratoma.  Better  than  any  other  growth  the  latter  can 
illustrate  the  formation  of  malignant  out  of  benign  growths. 
While  teratomata  may  originate  anywhere,  they  have  their 
peculiar  sites  for  development,  which  differ  largely  from  those 
of  cancer,  although  in  both  the  ovary  is  a  favorite  site.  Tera- 
toma is  purely  local  and  must  be  removed  surgically,  as  the 
bones,  skin,  teeth,  hair,  etc.,  which  they  contain  can  undergo 
neither  regression  nor  softening.  Somewhat  akin  to  teratomata 
are  mixed  tumors  which  contain  cancerous,  in  association 
with  some  connective  tissue  growth.  The  congenital  cancers, 
and  those  which  develop  in  connection  with  congenital  mal- 
formations, such  as  branchiogenous  cancer,  apparently  have 
little  in  common  with  typical  cancer.  Any  cancer  which  occurs 
in  subjects  well  below  the  cancer  age  may  be  regarded  as 
congenital,  and  purely  local,  without  any  element  of  general 
predisposition. 


NOSOLOGY  AND  RELATIONS  OF  CANCER  177 

Relations  of  Cancer  to  Certain  Constitutional  Diseases. — There 
can  hardly  be  a  doubt  that  the  rapid  diffusion  of  certain  forms 
of  cancer  stands  in  some  relationship  to  other  and  constitutional 
or  diathetic  affections  which  are  rapidly  increasing,  and  which 
are  especially  dependent  on  modern  white  civilization,  so  that 
they  are  jointly  spoken  of  as  " white  men's  diseases."  That 
these  affections  are  not  racial  but  due  to  the  mode  of  life  is 
apparent  from  the  fact  that  aboriginal  peoples  become  subject 
to  them  as  soon  as  they  begin  to  lead  the  lives  of  white  men, 
and  after  some  generations  are  as  much  if  not  more  subject  to 
the  said  affections  than  the  whites  themselves.  This  subject 
has  not  been  intensely  studied  and  we  can  only  scratch  at  the 
surface  of  it  in  these  pages.  Some  of  these  affections  bear 
little  resemblance  to  others,  yet  the  same  causal  factors  may 
enter  into  them. 

Dental  Caries. — This  condition  is  primarily  a  demineraliza- 

tion  of  the  teeth — a  decalcification — which  is  almost  universal 

among  modern  civilized  whites,  in  distinction  to  the  immunity 

of  the  native  black,  and  to  a  less  extent  the  American  Indian. 

The  explanation  of  its  dependence  on  acid  secretions  throws 

us  back  to  the  problem  of  acid  fermentation  as  a  factor,  but 

this  kind  of  speculation  throws  no  light  on  the  diffusion  of  the 

disease  in  modern  man,  as  distinguished  from  prehistoric  man, 

whose  teeth  simply  wore  out  but  did  not  decay.     The  common 

sense  explanation  is  that  with  modern  cookery,  and  the  choice 

of  certain  soft  foods,  the  teeth  have  too  little  to  do  and  undergo 

regressive  changes.     But  some  primitive  types  of  man  were 

bolters  of  their  food,  and  it  is  to  be  inferred  that  they  developed 

caries  as  a  natural  result,  while  those  whose  food  had  to  be 

chewed  before  it  could  be  swallowed  retained  their  teeth,  as 

not  a  few  do  today.     That  a  hereditary  or  cumulative  element 

is  involved  seems  to  be  shown  by  the  fact  that  caries  is  really 

a  disease  of  childhood  and  adolescenec  and  that  after  maturity 

the  condition,  while  present,  is  much  slower  in  evolution.    The 

teeth  which  have  weathered  the  first  few  decades  of  life  do  not 

give  much  trouble,  with  the  exception  of  the  wisdom  teeth. 
12 


178  CANCER 

Pyorrhea-alveolaris  replaces  caries  as  a  menace  in  the  later 
decades.  The  two  exclude  each  other  apparently,  because  in 
pyorrhea  the  reaction  is  alkaline,  while  in  caries  it  is  acid. 
Pyorrhea  has  also  shown  a  remarkable  increase  in  civilized 
white  men.  It  may  be  compared  in  some  ways  with  the  normal 
senile  retraction  of  the  gums  and  loosening  of  the  teeth,  but 
is  quite  distinct  from  this  process,  appearing  during  maturity 
and  having  a  distinct  pathological  mechanism.  Both  affections 
are  aggravated  by  the  lodging  of  food  particles  between  the 
teeth,  due  to  imperfect  alignment.  In  perfect  dentures  this 
lodgment  can  hardly  occur.  We  see,  therefore,  in  these 
dental  affections  the  operation  of  several  factors — evolution 
of  the  cranium,  disuse  of  the  teeth,  the  consumption  of  food 
softened  by  cookery  and  perhaps  without  proper  mineralization, 
and  various  local  factors. 

There  is  an  important  relationship  between  the  teeth  and 
endocrine  glands,  and  perhaps  with  the  vitamines.  Some 
dentists  isolate  thyroid,  pituitary  and  adrenal  types  of  teeth, 
and  we  know  that  in  scorbutus  the  gums  bear  the  brunt  of  the 
disease,  so  that  the  teeth  loosen  and  fall  out.  If  civilization 
means  a  strain  on  the  endocrine  apparatus,  as  is  claimed  by 
those  who  seek  the  simplest  and  most  universal  explanation 
of  the  spread  of  diseases,  it  would  not  be  difficult  to  formulate 
a  theory  to  show  such  relationship  between  defective  internal 
secretions  and  the  pathology  of  the  teeth. 

Before  going  further  we  may  speculate  a  little  on  the  possi- 
bility of  common  factors  between  the  spread  of  caries  and  that 
of  cancer.  Victims  of  the  latter  are  often,  if  not  commonly,  of 
apparently,  remarkable  physical  soundness,  with  well  preserved 
teeth,  and  caries  is  preeminently  a  disease  of  adolescence,  so  that 
there  is  little  analogy  between  the  affections  themselves. 
Robust  people,  well  preserved  and  with  good  teeth  are  by  no 
means  immune  from  pyorrhea.  But  we  are  not  interested  in 
comparing  the  diseases  themselves  but  only  the  common  causal 
factors. 

That  an  evolutionary  factor  is  concerned  in  the  spread  of 


NOSOLOGY  AND  RELATIONS  OF  CANCER  179 

some  cancers  is  not  impossible.  While  parous  women  suffer 
more  from  cancer  of  the  breast  and  cervix  than  the  single 
women,  it  must  be  remembered  that  when  women  were  con- 
tinually breeding  and  nursing  infants  and  raised  large  families 
cancer  of  these  organs  was  far  less  common  than  today.  Where 
limitation  of  families  is  the  rule,  as  in  most  civilized  countries, 
cancer  appears  to  flourish,  as  in  Holland  and  France.  The  one 
and  two  child  system  of  today  means  for  most  of  the  woman's 
life  the  breast  and  uterus  are  idle.  The  fact  that  the  woman 
who  has  borne  children  is  more  menaced  than  the  single  and 
nulliparous  woman,  may  be  explained  by  the  handicap  of  past 
mastitis,  cervical  lacreation,  and  other  local  factors,  but  back 
of  all  may  be  the  factor  of  disuse,  with  the  tendency  to  earlier 
involutional  changes  long  before  the  menopause.  The  inability 
of  so  many  young  women  to  nurse  their  children  points  more 
than  any  other  factor  to  evolutionary  causal  moments,  and 
suggests  that  the  time  may  come  when  the  maternal  functions 
will  be  greatly  in  abeyance  as  a  racial  characteristic,  and  that 
sterility,  abortion,  low  natality,  etc.,  will  rapidly  increase. 
Another  evolutionary  development  is  female  sexual  frigidity, 
which  according  to  Havelock  Ellis  is  a  development  of  the  past 
150  years.  Vaginismus,  not  known  before  Marion  Sims'  dis- 
covery, is  now  extremely  common.  Rapid  increase  of  divorce 
may  also  be  mentioned  in  the  same  connection.  Hence  he  would 
be  a  bold  man  who  should  deny  that  there  is  some  correlation 
between  increase  of  cancer  of  the  breast  and  uterus  on  the  one 
hand,  and  all  of  the  race  suicidal  factors  just  enumerated  on 
the  other. 

Another  factor  which  may  be  compared  with  disuse  deserves 
mention;  a  disuse  of  the  muscles,  or  lack  of  exercise.  Despite 
numerous  faddish,  modern  activities,  the  normal  woman  of  the 
past  was  very  different  from  the  modern  woman ;  she  was  one 
of  the  busiest  of  beings,  who  really  worked  and  did  not  play  at 
work.  She  was  on  her  feet  most  of  the  time  and  doubtless 
walked  miles  a  day  in  her  household,  climbing  stairs  included. 
Her  metabolism  was  also  constantly  stimulated  by  gestation  and 


180  CANCER 

lactation,  and  there  was  little  chance  for  the  development  of 
sluggish  metabolism  and  its  attendent  diseases.  The  modern, 
well-to-do  woman  lies  abed  late,  has  servants,  gets  about  with 
a  car,  and  must  burn  up  a  relatively  small  amount  of  food, 
including  bonbons,  with  which  she  is  tempted.  Much  the  same 
line  of  argument  pertains  to  cancer  in  men. 

In  regard  to  cancer  in  other  localities,  some  of  this  line  of 
thought  may  not  hold  in  regard  to  the  considerable  increase  in 
cancer  of  the  stomach  in  women,  a  fact  most  difficult  to  explain 
and  which  we  will  not  attempt  in  this  connection.  Woman  is 
somewhat  immune  to  buccal  cancer,  or  has  been  in  the  past. 
At  one  time  it  was  unusual  to  see  a  cancer  of  the  tongue  in 
women.  As  shown  by  the  frequency  of  smoker's  cancer  and 
betel-nut,  or  buyo  (Philippine  cancer)  irritation  plays  a  great 
role  in  this  location.  Three  causes  of  cancer  in  the  buccal  area 
are  said  to  be  responsible  for  the  rapid  increase  in  the  male — 
tobacco,  syphilis,  and  alcohol,  to  which  may  be  added  the  con- 
sumption of  hot  tea  and  coffee.  None  of  these  factors  obtain 
in  primitive  people  but  buyo  cancer  shows  that  there  is  no 
natural  immunity  to  the  disease.  The  word  civilization  hardly 
fits  the  introduction  of  bad  habits  into  a  primitive  community, 
and  sophistication  seems  a  much  better  term.  The  betel  chewer 
is  a  sophisticated  person  at  least,  for  he,  or  she,  has  a  vice  which 
like  tobacco,  whiskey,  and  venery  leads  to  disease.  We  have 
digressed  a  good  deal  from  the  subject  of  caries  and  pyorrhea  as 
a  white  man's  disease,  and  will  next  speak  of : 

Early  Baldness  and  Canities. — These  affections  are  eminently 
of  the  class  which  we  are  discussing,  and  are  set  down  to  evolu- 
tionary factors,  hair  being  no  longer  a  necessity.  The  white 
man  seems  to  have  been  the  only  hairy  man  among  the  primitive 
peoples,  and  at  one  time  is  believed  to  have  inhabited  the  cold 
countries  and  to  have  been  covered  from  head  to  foot.  With 
the  need  for  such  a  protective  covering  no  longer  apparent,  he 
would  naturally  lose  it  as  he  began  more  and  more  to  clothe 
himself.  The  darker  races  must  have  lost  their  hirsute  covering 
at  a  much  earlier  period,  as  far  as  the  face,  body  and  limbs  are 


NOSOLOGY  AND  RELATIONS  OF  CANCER  181 

concerned,  but  on  the  other  hand  do  not  suffer  from  baldness  of 
the  scalp  or  canities  until  very  old.  The  problems  of  the  hair, 
of  the  head,  beard,  and  general  surface  must  be  kept  separate, 
being  under  different  conditions.  Thus  in  the  white  man,  the 
beard  and  facial  hair  in  general  is  largely  a  sexual  characteristic 
while  the  scalp  hair  in  women  has  similar  significance. 

In  regard  to  baldness  the  type  differs  in  man  and  woman,  intro- 
ducing another  sex  element.  The  growth  and  distribution  of  hair 
is  intimately  associated  with  the  endocrine  organs,  as  is  seen  in 
mild  sex  confusion.  Premature  baldness  and  greyness  also  run 
in  families  and  are  often  inherited.  In  regard  to  the  mechanism 
of  baldness  it  stands  in  some  relationship  to  a  hidebound  state 
of  the  scalp.  This,  the  most  important  feature  in  baldness,  is 
barely  mentioned  by  authors.  In  senile  baldness  the  hair  first 
turns  grey,  but  this  is  not  seen  in  the  premature  form.  The 
general  use  of  the  Derby  hat  has  been  accused  as  responsible  in 
part  for  early  baldness,  which,  if  true,  is  an  example  of  the 
effects  of  civilization  or  sophistication.  This  is  like  attributing 
cancer  of  the  breast  to  the  use  of  corsets — it  cannot  be  proved  or 
disproved.  Enough  has  been  said  to  point  out  evolutionary 
factors  and  disuse  of  the  hair  which  no  longer  has  any  office 
to  perform,  or  disuse  of  the  muscles  which  corrugate  the  scalp; 
endocrine  factors  disturbing  the  hair  growth;  effects  of  civiliza- 
tion as  seen  in  the  rigid  hat,  etc.  Baldness  seems  far  more  com- 
mon in  the  high-brow  type  of  man  than  in  the  more  primitive 
white  men,  and  in  this  way  be  the  consequence  of  increased 
mental  activity — resulting  from  ambition,  from  business  compe- 
tition, worry,  etc.  This  factor  must  be  reckoned  with  in  white 
men's  diseases — anxiety  for  the  future.  Since  many  athletes 
suffer  from  early  baldness  it  can  hardly  be  attributed  to  slow 
or  defective  metabolism.  Not  much  appears  to  be  known  about 
early  greying  of  the  hair,  save  that  an  emotional  factor  is  present 
at  times  and  that  it  may  be  familial  and  hereditary.  It  stands 
in  some  relationship  to  depigmentation  of  the  skin,  which  places 
it  among  the  affections  influenced  by  internal  secretions. 

Other  affections  rapidly  increasing  in  the  past  50  years  among 


I 82  CANCER 

civilized  or  sophisticated  whites  are  arteriosclerosis,  cardio- 
vascular disease  in  general,  nephritis,  appendicitis,  diabetes,  so- 
called  atypical  gout  or  uric  acid  disease,  neurasthenia,  insanity, 
metasyphilitic  affections,  sexual  shortcomings  of  various  kinds 
etc.  The  same  causal  factors  can  be  detected  in  all,  plus  other 
factors. 

Arteriosclerosis. — The  affection  thus  called  is  believed  to  be 
rapidly  increasing  as  a  so-called  malady  of  civilization,  and  some 
evidence  of  its  precocious  appearance  is  a  natural  consequence 
of  this  diffusion.  Its  occurrence  in  those  who  work  at  hard 
manual  labor  is  not  known  to  be  on  the  increase,  but  it  now  pre- 
vails more  in  the  brain  worker  and  sedentary  persons.  The 
cancer  subject,  although  he  may  have  a  high  blood  pressure 
proportional  to  his  age,  is  said  to  be  remarkably  exempt  from  a 
high  degree  of  arteriosclerosis,  and  the  per  cent  of  the  latter, 
found  in  a  series  of  autopsies  on  cancer  victims,  was  found  to  be 
not  above  15.  Nevertheless,  it  is  more  than  likely  that  the 
causal  factors  of  the  two  maladies  partly  coincide.  According 
to  Bishop  the  typical  arteriosclerotic  subject  here  in  the  United 
States  is  rugged  and  sound  and  of  good  stock,  who  has  an  un- 
usual capacity  for  work  and  is  not  sensible  of  fatigue.  He  works 
incessantly  and  he  constantly  assumes  responsibilities  which  he 
must  then  fulfil.  He,  no  doubt,  eats  to  excess  and  often  his 
diet  is  unbalanced.  Syphilis  as  a  factor  may  be  excluded  as 
causing  other  types  of  arterial  disease,  although  in  some  cases, 
such  as  coronary  sclerosis,  both  factors  seem  to  be  present.  The 
arteriosclerotic  improves  under  mental  rest,  moderate  physical 
exercise  and  restriction  of  diet,  with  elimination  of  protein. 
The  nervous  and  endocrine  factors  are  very  evident  in  arterio- 
sclerosis, apparently  much  more  than  in  cancer,  and  in  many 
cases  there  is  a  history  of  some  infection  such  as  typhoid  and 
septicemia.  The  cancer  subject  often  is  immune  to  infectious 
diseases,  or  else  has  had  the  good  fortune  to  escape  them. 
Closely  related  to  arteriosclerosis  is  one  form  of  kidney  disease 
which  is  not  due  to  the  ordinary  types  of  nephritis,  although 
classed  among  them.     At  one  time  cancer  was  attributed  to  a 


NOSOLOGY  AND  RELATIONS  OF  CANCER  183 

nervous  element — worry,  sickness  and  death  in  the  family,  and 
business  reverses — but  it  is  questionable  if  it  is  not  only  natural 
in  people  of  the  cancer  age  to  have  encountered  losses  and 
reverses.  Although  these  nervous  disturbances  can  derange 
metabolism,  and  so  produce  the  erroneous  blood  current  which 
leads  up  to  the  wrong  action  of  cells  ending  in  cancer. 

ETIOLOGICAL  FACTORS  IN  CANCER 

The  Congenital,  Hereditary,  and  Familial  Element. — In  seeking 
to  arrive  at  the  causal  nexus  of  disease  this  is  perhaps  the  first 
element  to  investigate.  If  we  argue  that  man  ascended  from 
the  lower  forms  of  life  by  evolution  or  mutations,  the  fact  that 
morbid  growths  occur  in  insects,  fishes  and  amphibia,  to  say 
nothing  of  warm-blooded  animals,  will  tend  to  show  that  the 
malady  is  inseparable  from  the  growth  of  all  highly  organized 
life.  The  local  origin  of  cancer  in  the  frog,  according  to  Kopsch, 
appears  to  be  a  very  simple  matter.  Certain  nematode  worms 
in  the  larval  state  cause  what  are  known  as  worm  nodes,  and  a 
secretion  or  excretion  of  these  larvae  is  able  to  start  up  almost 
every  form  of  neoplasm  known  to  man.  There  are  no  typical 
growths,  but  adenoma,  carcinoma,  sarcoma,  etc.,  are  seen  to  be 
represented  in  the  microscopic  slides  of  these  tumors.  Whether 
any  other  irritant  can  induce  the  genesis  of  these  tumors  does 
not  appear.  As  far  as  we  know  there  is  no  predisposition 
involved,  but,  of  course,  this  has  not  been  investigated  yet,  and 
perhaps  is  impossible  of  discovery.  In  the  so-called  cancer-like 
tumors  of  the  thyroid  in  certain  genera  of  fishes,  the  genesis  of 
the  tumor  is  very  dissimilar  from  the  preceding,  and  seems  to 
depend  on  something  in  the  water,  as  in  the  case  of  human  goitre. 
In  mammals,  with  the  exception  of  mice  and  rats  used  in  labor- 
atory experiments,  we  have  but  little  knowledge  of  malignant 
disease.  As  far  as  we  know  it  attacks  domestic  animals  much 
more  than  those  in  a  wild  state,  flesh  eaters  oftener  than  herbi- 
vora,  and  stall-fed  horses,  etc.,  more  frequently  than  animals 
which  run  wild.  This  is  exactly  what  we  should  expect  from  a 
study  of  cancer  in  man. 


I 84  LANCER 

There  is  no  reason  to  believe  that  primitive  man  suffered 
to  any  extent  from  cancer,  and  even  the  earliest  civilizations, 
although  much  like  our  own  in  some  respects,  are  not  accused 
of  producing  this  malady  on  a  large  scale:  this  also  holds  good 
for  medieval  civilization,  after  the  passing  of  the  Dark  Ages. 
Flocking  to  cities,  commingling  of  races,  wide  spread  luxury 
and  sophistication  of  the  people,  were  apparently  incapable  of 
producing  cancer,  or  other  of  the  so-called  white  man's  diseases. 
Whatever,  today  is  responsible  for  the  rapid  increase  of  cancer 
must  also  be  responsible  for  the  multiplication  of  a  dozen  other 
morbid  conditions,  which  as  far  as  is  known  did  not  prevail 
in  former  civilizations.  These  conditions  have  little  in  com- 
mon, aside  from  their  community  of  origin.  Hence  those  who 
seek  for  a  formula  which  simplifies  everything,  explain  all 
these  affections  by  the  theory  of  evolution  or  mutation.  The 
entire  subject  is  covered  in  the  section  on  the  relation  of  cancer 
to  other  constitutional  affections. 

In  regard  to  the  immediate  inheritance  of  cancer  patients, 
who  are  themselves  prone  to  appear  particularly  healthy,  it 
may  be  stated  that  the  ancestry  is  by  no  means  always  as 
sound  as  might  be  inferred.  While  many  ancestors  of  a 
cancer  patient  may  have  been  healthy  and  long  lived,  there 
are  often  among  the  collateral  ascendants  cases  of  tuberculosis 
or  psychoses.  But  not  many  of  the  families  of  cancer  subjects 
have  been  studied  to  date. 

If  we  assume  that  cancer  is  a  matter  of  individual  soil  rather 
than  of  active  causes,  it  should  show  the  same  degree  of  heredity 
as  is  seen  in  other  racial  scourges,  like  gout.  But  the  inherit- 
ance of  cancer  is  a  very  unstable  quantity.  In  some  figures 
quite  a  respectable  percentage  of  heredity  is  in  evidence,  while 
in  other  material  the  element  seems  quite  lacking.  If  we 
judge  by  averages,  the  inherited  contingent  is  relatively  small 
and  doubtful.  But  that  cancer  families  do  rarely  exist,  is 
undoubted,  although  but  few  good  examples  are  on  record. 
In  such  families,  with  numerous  cases  in  three  or  four  gener- 
ations, we  note  a  tendency  to  early  incidence  and  to  attack, 


NOSOLOGY  AND  RELATIONS  OF  CANCER  185 

in  unusual,  and  often  the  same  localities.  In  this  way  familial 
cancer  simulates  racial  cancer.  In  other  words,  increase  of 
cancer  in  a  single  strain  of  mankind  imitates  increase  in  the 
community,  and  may,  of  course,  be  due  to  similar,  continued 
modes  of  life. 

The  sudden  increase  of  cancer  in  a  community  is  sufficient 
evidence  that  heredity  can  play  but  a  slight  role  therein.  It 
also  eliminates  slow  evolutionary  processes,  and  causes  us  to 
think  of  mutations,  either  of  the  tissue  cells  or  of  individual 
human  beings.  In  a  relatively  short  time  mankind  has  passed 
from  a  non-cancerous  to  a  cancerous  race.  Only  a  few  years 
ago  cancer  was  almost  a  medical  curiosity — a  special  visitation 
on  some  unfortunate  wight;  today  with  the  odds  of  developing 
cancer  are  shortened  to  something  like  8  to  1  for  middle-aged 
subjects,  the  malady  is  one  which  dominates  most  others. 

There  is  no  better  illustration  of  the  difference  between 
hereditary  and  congenital  disease. than  is  offered  in  this  affection 
The  congenital  element  in  cancer  differs  from  the  inherited 
factor.  Students  of  cancer  as  a  racial  malady,  which  is  rapidly 
increasing,  find  but  little  to  interest  them  in  the  study  of  con- 
genital cancer.  The  latter  naturally  affects  young  subjects, 
and  hence  is  extremely  rare.  No  one  knows  the  real  age  limit 
in  congenital  cases,  but  there  is  a  suspicion  that  most  instances 
of  cancer  in  the  young  who  are  well  below  the  lower  limit  of 
the  cancer  age,  are  congenital.  Since  the  rapid  diffusion  of 
cancer  causes  it  to  appear  in  younger  and  younger  subjects, 
a  border  line  arises  in  which  it  is  impossible  to  distinguish 
between  congenital  and  spontaneous  cancer.  In  such  cases 
much  depends  on  the  locality.  If  the  latter  is  one  in  which 
the  adult  is  commonly  attacked,  like  the  rectum,  we  should  be 
able  to  exclude  the  congenital  factor.  If  the  liver,  where 
primary  cancer  is  extremely  rare,  the  latter  may  be  accused. 
It  has  been  said  that  cancer  in  early  life  is  always  an  example 
of  a  mixed  tumor,  and  hence  congenital.  The  same  holds  good 
for  cancer  which  develops  in  association  with  some  congenital 
malformation,  even  if  at  a  late  date.     Moreover,  all  malignant 


I 86  CANCER 

tumors  known  to  develop  from  misplaced  embryonal  "rests" 
while  very  seldom  cancerous,  are  naturally  congenital.  Malig- 
nant growths  which  originate  at  any  time  of  life  in  congenital 
nevi,  may  in  a  way  be  regarded  as  congenital. 

Heterotopia. — Before  leaving  this  subject  another,  that  of 
heterotopia — should  be  considered  more  fully.  While  it  may 
be  associated  with  hereditary  and  congenital  components,  it 
may  also  exist  in  the  absence  of  such  factors.  It  may  enter 
into  the  subject  of  wound  repair  and  inflammatory  sequelae. 
In  its  relation  with  embryology  it  may  exhibit  wide  differences. 
Thus,  in  the  very  period  of  development  the  trophoblastic 
cells  may  be  included  in  the  development  of  the  individual. 
This  is  hardly  possible  to  prove,  but  if  such  cells  were  to  lie 
latent  in  the  tissues,  and  then  be  aroused  to  proliferate,  they 
should  possess  much  resemblance  to  cancer  growth,  being 
without  other  function  than  to  grow  at  will. 

The  trophoblastic  hypothesis  receives  a  demonstration  in 
chorio-epithelioma  of  the  uterus,  in  which  decidual  cells,  re- 
maining in  the  uterine  wall,  are  activated  to  malignant  growth 
by  some  unknown  force,  thought  to  depend  on  the  ovarian 
secretion.  But  according  to  this  conception  of  cancer  in 
general,  the  latter  should  behave  as  a  chorio-epithelioma, 
which,  as  is  elsewhere  shown,  differs  notably  from  cancer. 
Chorio-epithelioma  also  constitutes  the  malignant  component 
in  malignant  teratoma,  which  is  also  distinct  from  cancer. 
In  these  teratomata,  especially  those  with  considerable  pro- 
duction of  fetal  tissues,  the  presumable  source  is  not  the 
trophoblast;  the  tumor  originates  in  a  twin  conception  unioval, 
in  which  only  one  individual  is  produced,  abortive  remains 
of  the  other  having  been  infolded  into  its  tissues.  This  origin 
is  sometimes  unquestionable,  and  in  other  cases  may  be  in- 
ferred, and  the  theory  explains  the  majority  if  not  all  of  the 
teratomata.  By  heterotopia  authors  refer  to  a  displacement 
of  cells  which  occurs  in  the  course  of  the  ordinary  evolution 
of  the  fetus  in  which  neither  a  trophoblast  nor  a  fetal  con- 
clusion is  concerned. 


NOSOLOGY  AND  RELATIONS  OF  CANCER  187 

During  the  brief  embryonal  period  in  which  organ-genesis 
occurs,  every  opportunity  is  offered  for  displacement  of  the 
various  cells,  and  confusion  of  tissues.  Many  such  displace- 
ments are  transitory,  and,  owing  to  some  inherent  principle, 
this  tendency  to  displacement  is  spontaneously  corrected. 
Wherever  there  has  been  an  infolding  of  the  epiblast,  portions 
of  epithelial  tissue  may  be  included  in  the  tissues  of  the  meso- 
blast.  In  this  way  certain  types  of  cancer  appear  to  have  their 
origin.  That  most  commonly  cited  develops  in  the  site  of 
the  branchial  clefts,  a  temporary  structure  of  embryonal  life. 
Incomplete  development  may  leave  a  cyst  or  fistula,  and  in 
middle  life  a  strong,  robust  man  may  have  cause  to  develop 
cancer  in  that  location. 

Facts  of  this  sort  have  given  more  or  less  support  to  the  heter- 
otopic theory  of  cancer  genesis.     To  enumerate  all  of  the  possi- 
bilities of  this  origin  would  be  to  repeat  much  of  embryology, 
but  not  only  does  cancer  commonly  develop  where  such  a 
theory  is  inadmissible,  but,  on  the  other  hand,  in  cases  where 
embryological  confusion  exists  cancer  may  fail  to  develop.     In 
addition,  the  malignant  growth  in  these  cases  may  not  be 
cancerous  in  the  strict  sense,  but  may  be  a  teratoma,  sarcoma, 
hypernephroma,  etc.     The  latter  seems  to  be  due  to  an  infold- 
ing of  the  adrenal  body  by  the  kidney.     It  is  enough  to  state 
that  it  is  recognized  that  malignant  tumors,   among  which 
cancer  is  included,  may  at  times  have  a  heterotopic  origin,  but 
that  such  growths  are  rare  and  not  increasing,  and  are  local 
and    surgical  at  first,  and,  so   this  aspect  does  not  touch  the 
cancer  problem.     If,  as  Ewing  emphasizes,  cancer  of  the  breast 
may  originate  from  misplaced  sweat  glands,  we  have  a  heter 
otopic  factor,  but  it  is  powerless  to  account  for  the  r» 
of  the  disease,  or  explain  why  a  low  grade  of  m?"'' 
neoplastic  formation.     The  claim  that  cancv>- 
oriftce  of  the  body  because  , 
otopia,  does  not  appear  to  ' 
of  the  rival  belief  of  me' 

Finally  there  art' 


1 88  CANCER 

growths  and  congenital  ones.  The  latter,  however,  arise  com- 
paratively early  in  life,  and  a  heterotopic  factor  may  or  may  not 
be  present.  As  we  have  already  seen,  branchiogenic  cancer 
appears  as  a  rule  in  middle  life,  although  dependent  on  a  marked 
congenital  anticedent.  It  is  asserted  that  mixed  growths  in 
which  cancer  develops  in  association  with  some  mesoblastic 
tissue,  usually  appear  early  in  life.  Such  mixed  tumors  are  not 
classed  among  the  teratomata.  After  extensive  injuries  fol- 
lowed by  repair  it  is  possible  for  an  acquired  heterotopia  to 
occur,  and  scar  cancer  may  have  this  factor  present. 

Metaplasia,  Anaplasia,  Etc. — These  terms  are  in  extensive 
use  to  account  in  part  for  the  genesis  of  cancer.  The  term 
metaplasia  originally  connected  the  degradation  of  a  higher  to  a 
lower  type  of  tissue,  but  in  epithelial  metaplasia  it  means  no 
more  than  the  appearance  of  one  kind  of  epithelium  in  the  midst 
of  another.  Thus,  occasionally  a  focus  of  squamous  cell  can- 
cer is  seen  in  the  midst  of  the  columnar  epithelium  of  the 
stomach,  or  in  the  lining  of  cyst.  When  this  apparent  trans- 
position occurs  close  to  a  transition  point  between  squamous 
and  columnar  epithelium,  as  in  the  cervix  uteri,  we  may  speak  of 
it  as  an  illustration  of  heterotopia,  and  it  has  been  attempted 
to  account  for  the  frequency  of  cancer  of  the  cervix  in  this 
manner.  But  metaplasia  of  this  sort  may  be  acquired  as  the 
result  of  inflammation,  wherein  the  destruction  of  the  colum- 
nar epithelium  may  be  succeeded  by  the  appearance  of  the 
squamous  form. 

Metaplasia  does  no  more  than  explain  the  formation  of  certain 
types  of,  cancer,  or  rather  only  describes  them.  In  the  absence 
of  some  efficient  cause,  like  heterotopic  displacement,  we  are 

;fe  unable  to  explain  why  a  squamous  cell  cancer  can  develop 
-*lnmnar  epithelium  and  vice  versa.     While  metaplasia 
"inal  portion  of  the  cervix  uteri,  it  plays  a  small 
general. 

e  terms  do  not  throw  light  on 

ave  some  descriptive  value. 

'itic  metamorphosis  of 


NOSOLOGY  AND  RELATIONS  OF  CANCER  189 

the  cancer  cell  from  a  normal  or  healthy  cell.  Anaplasia  is 
applicable  as  a  term  only  to  malignant  tumor  cells,  and  what- 
ever may  characterize  the  latter,  while  mutation  is  universally 
applicable  to  living  individuals,  and  is  a  well  known  pheno- 
menon in  both  plant  and  animal  life.  Moreover,  mutation 
may  be  created  at  will,  and  mutations  will  arise  from  various 
factors,  such  as  feeding  on  a  special  pabulum,  crossing  of 
breeds  or  strains,  etc.  Malignant  cells  have  usually  been 
regarded  as  involving  regression  of  higher  to  lower  cell  forms, 
but  mutation  does  not  possess  such  significance,  and  implies 
the  creation  of  a  new  species  from  an  old  one.  These  subjects 
strike  us  as  academic  in  the  discussion  of  cancer  as  a  racial 
plague. 

Immunity  and  Susceptibility.-— These  terms,  one  of  which 
implies  the  other,  may  be  discussed  from  general  and  special 
viewpoints,  the  latter  of  which  come  up  under  age,  site,  occupa- 
tion, race,  etc.  There  seems  to  be  no  absolute  immunity 
to  cancer  anywhere  among  the  metazoa,  although  the  disease 
may  not  have  been  encountered  as  low  as  the  radiata,  mol- 
lusks,  arthropods,  and  annelides.  Among  mankind  there 
is  no  absolute  immunity,  despite  the  fact  that  in  certain  races 
and  at  certain  times  of  life  the  disease  is  extremely  rare.  The 
perfect  health  which  can  throw  off  all  other  maladies  does 
not  protect  from  cancer,  and  even  those  who  appear  supernorm- 
ally  robust  seem  specially  menaced  by  the  disease;  although 
the  latter  may  also,  on  rare  occasions,  attack  a  subject  in  the 
terminal  stage  of  tuberculosis  or  other  disease.  Perhaps  the 
nearest  example  of  immunity  is  seen  in  the  leper,  who,  however, 
does  not  usually  live  far  into  the  cancer  age.  It  was  shown,  at 
least  for  Sweden,  that  individuals  who  have  been  immune 
from  infections  in  the  past,  even  from  the  ordinary  affections 
of  childhood,  were  in  a  majority  among  cancer  victims. 

It  is  the  same  with  the  community  as  with  the  individual. 
The  more  healthy  the  locality  and  the  lower  the  death  rate,  the 
greater  is  the  tendency  to  cancer,  at  least  in  certain  countries, 
as  in  England  and  New  Zealand. 


190  CANCER 

In  regard  to  the  state  of  nutrition,  the  thin  subject  has  a 
sort  of  immunity  which  gives  him  a  better  prognosis  than  the 
fat  subject,  or  at  least  this  seems  true  of  cancer  of  the  breast,  for 
reasons  already  mentioned.  This  does  not  mean  that  she  is 
less  susceptible  to  the  disease — although  she  may  be.  We  have 
no  figures  to  quote,  but  in  New  York,  at  least,  the  large  share  of 
cancer  patients  are  stout,  and  many  flabby. 

Subjects  with  continued  high  fever  are  perhaps  largely 
immune  for  the  time  being,  although  this  statement  is  apparen- 
tly contradicted  by  the  occasional  development  of  cancer  in 
advanced  tuberculosis.  Erysipelas  has  some  power  in  restrain- 
ing the  growth  of  sarcoma,  but  this  may  be  through  its  toxin 
action.  Mice  heated  in  an  artificial  environment  cannot  be 
inoculated  with  cancer. 

Dietetic  immunity  and  susceptibility  is  so  important  a 
subject  that  it  will  be  separately  considered.  It  is  of  course 
very  difhcult  to  separate  the  dietetic  component  from  the 
hygienic,  and  the  entire  subject  is  best  considered  under  the 
head  of  the  relationship  between  diet  and  cancer,  and  also 
civilization  and  cancer,  of  which  dietetics  form  an  important 
sub-division.  It  is  one  thing  to  discuss  the  causation  of  cancer 
and  quite  another  to  consider  the  cause  of  the  increase  of  the 
same.  Since  cancer  is  often  preceded  by  some  local  alteration 
in  situ,  whatever  tends  to  induce  this  local  change  will  also 
cause  increased  frequency.  Local  factors  will  be  discussed  in 
due  season. 

Neoplastic  Diathesis. — The  plausible  statement  has  been 
made  that  this  is  shown  in  the  small  superficial  neo-plasms 
which  are  usually  multiple;  thus,  one  subject  may  present 
numerous  moles,  fleshy,  pigmented,  hairy,  etc.,  along  with  nevus 
araneus,  while  another  may  be  free  from  such  .developments 
entirely.  Aside  from  the  fact  that  these  nevi  themselves  may 
become  cancerous  at  times,  the  further  claim  is  made  that  in 
the  same  subjects  there  is  a  greater  tendency  to  neoplastic 
formation,  and  that  the  said  individuals  are  more  apt,  than 
others  with  smooth  skins,  to  develop  both  benign  and  malig- 


NOSOLOGY  AND  RELATIONS  OF  CANCER  191 

nant  growths.  We  have  never  seen  any  statistics  bearing  on 
this  point.  In  the  same  connection  may  be  mentioned  senile 
keratosis  and  verrucosis. 

Endocrinic  Factor. — As  if  by  exclusion,  the  endocrine  system 
has  been  made  responsible  for  the  development  of  cancer,  since 
it  begins  to  fail  in  its  activities  as  the  cancer  age  is  approached. 
Nature  is  believed  to  exert  a  check  on  the  development  of 
cancer  either  by  the  formation  of  antibodies  in  the  blood  or  by 
local  defensive  forces,  and  the  withdrawal  of  this  protection 
may  make  it  possible  for  certain  cell  growth  stimulants  to  rouse 
the  certain  cells  to  cancer  activity.  It  does  seem  that  endocrine 
factors,  when  the  balance  is  disturbed,  may  act  as  excitants  of 
cancer,  as  is  shown  by  the  fact  that  it  is  claimed  that  ovariotomy 
will  inhibit  the  growth  of  cancer.  It  has  already  been  shown 
that  accumulation  of  lutein  material  in  the  ovary  makes 
possible  the  formation  of  chorio-epithelioma  in  the  uterus. 
That  thyroid  is  able  at  times  to  retard  cancer  growth  may  be 
due  to  its  ability  to  reduce  the  amount  of  adipose  tissue,  as 
obesity  is  looked  on  as  unfavorable  in  certain  cancers  (breast) . 
Secretin  has  been  credited  with  the  comparative  immunity  of 
the  duodenum.  But  the  only  direct  evidence  of  a  relationship 
between  endocrinic  activity  and  cancer,  is  found  in  the  dimin- 
ished tolerance  to  glucose  usually  encountered  in  subjects  of 
carcinoma;  this  resource  is  actually  in  use  in  the  diagnosis  of 
internal  and  occult  cancer.  It  also  indicates  a  point  in  common 
with  diabetes. 

Special  Immunity  and  Susceptibility. — These  may  be  racial, 
chronological,  topographical,  occupational,  etc.  There  is  no 
true  racial  immunity,  as  far  as  is  known,  for  when  the  primitive 
and  aboriginal  or  dark  races  begin  to  live  the  lives  of  white  men, 
eating  their  food,  sharing  their  habits  and  occupations,  wearing 
their  clothing,  and  bearing  their  responsibilities,  they  contract 
cancer  like  the  white  men,  and  their  descendants  are  fully  as 
susceptible  as  the  whites.  Indians  living  on  their  reservations, 
enjoy  a  high  degree  of  immunity,  which  evidently  is  not  shared 
by  those  who  live  as  ordinary  whites.     A  study  of  these  Indians 


192  CANCER 

might  give  us  the  entire  key  to  the  riddle  of  cancer,  but  such 
has  not  been  made.  Are  these  reservation  Indians  also 
immune  to  other  white  man's  diseases? 

It  is  not  necessary  to  go  into  the  geographical  pathology 
of  cancer  in  this  connection  as  it  has  already  been  considered. 
We  may  state  without  contradiction  that  primitive  and  pure 
blooded  races,  living  in  a  state  of  nature,  are  largely  immune 
from  cancer,  and  that  this  is  not  wholly  a  matter  of  diet,  for  the 
more  or  less  carnivorous  Eskimos  is  said  to  be  immune;  but 
he  lives  largely  on  fats,  and  also  is  said  to  devour  the  contents  of 
the  stomachs  of  animals  killed,  which  consist  largely  of  mosses, 
etc. 

But  increase  in  the  consumption  of  protein  has  been  clearly 
shown  by  many  to  be  a  factor  in  the  production  of  cancer 
when  man  is  living  in  a  sophisticated  state;  in  other  words, 
the  dietetic  factor  may  loom  large  in  civilized  man  but  not  in 
primitive  man.  The  latter,  if  he  indulge  freely  in  meat,  may 
escape  cancer  from  the  absence  of  other  factors.  Meat  is  to 
be  feared  chiefly  when  it  cooperates  with  several  other  elements 
which  make  up  the  difference  between  civilized  and  savage  life. 
The  oft  quoted  figures  for  cancer  in  India  in  1904  would  seem  to 
show  that  the  diet  made  little  difference,  the  vegetarians  even 
being  largely  affected.  But  a  study  of  these  and  all  similar 
statistics  shows  that  almost  all  the  cases  were  of  cancer  in  the 
mouth,  and  that  the  chief  cause  of  this  was  betel  chewing,  so  that 
diet  could  exert  but  a  slight  controlling  influence,  or  rather  none 
at  all,  in  the  presence  of  such  a  powerful  exciting  local  cause. 

In  regard  to  age  incidence,  there  is  a  radical  difference  of 
opinion  as  to  the  existence  of  a  cancer  age.  According  to  one 
view  cancer  occurs  at  all  ages,  very  rarely  in  infancy  and  child- 
hood, a  little  more  frequently  in  adolescence,  still  more  fre- 
quently in  early  adult  life,  but  thus  far  of  decidedly  rare 
incidence  during  that  period.  Then  the  frequency  advances 
by  leaps  and  bounds,  until  we  reach  the  period  of  old  age,  when 
there  is  an  apparent  falling  off,  due  in  reality  to  the  relatively 
few  people  of  late  cancer  age;  in  truth  cancer  continues  to 


NOSOLOGY  AND  RELATIONS  OF  CANCER  1 93 

increase  with  years,  even  to  the  extreme  of  longevity.     From 
this  angle  there  is  no  such  thing  as  a  cancer  age. 

The  other  view  appears  to  hold  that  the  few  cases  of  cancer 
in  infancy  and  childhood  are  congenital,  and  should  not  be 
counted  in  morbidity.  Cases  in  adolescence  even  may  be 
found  to  be  atypical,  often  belonging  to  the  so-called  mixed 
tumors,  and  hence  congenital.  All  cases  occurring  up  to  the 
age  of  35  are  infrequent,  and  simply  to  be  classed  as  precocious, 
after  the  fashion  of  other  diseases,  like  gout  for  example,  which 
may  begin  in  early  life,  although  eminently  a  disease  of  middle 
age.  The  true  cancer  age  begins  at  35  or  40,  and  the  disease 
increases  in  frequency  up  to  a  certain  age,  when  perhaps  it 
slowly  declines  in  its  ratio.  This  latter  view  of  cancer  in  the 
aged  seems  to  have  been  regarded  as  settled  until  recently, 
when  a  thorough  study  of  tabulations  by  Whitman  appeared 
to  show  that  there  is  no  period  of  equilibrium  and  decline,  and 
that  the  older  a  subject  the  more  likely  he  is  to  develop 
cancer. 

When  the  disease  is  rapidly  extending  in  a  community  the 
tendency  is  to  attack  persons  both  younger  and  older  than  the 
typical  cancer  subject,  and  there  is  no  doubt  that  many  cases 
now  being  published  as  carcinoma  in  adolescents  and  children 
are  such  as  in  the  past  would  have  been  classed  as  sarcoma. 

There  has  usually  been  accepted  a  law  involving  age  and 
malignancy,  which  states  that  the  younger  the  subject  the 
greater  the  malignancy.  To  such  a  law  there  are  numerous 
exceptions.  Thus,  in  cancer  of  the  nasal  fossae,  which  may  at- 
tack very  young  subjects,  the  degree  of  malignancy  in  the  latter 
is  surprisingly  low,  while  in  the  aged  the  course,  which  should  in 
theory  be  slow,  is  very  rapid  and  malignant.  As  is  well  known, 
cancer  in  this  locality  is  slow  to  infiltrate  the  surrounding 
tissues  and  seldom  causes  metastases.  The  chief  peril  is  seen 
in  extension  to  the  cranial  cavity,  death  commonly  being  due  to 
meningitis.  Cancer  of  the  vault  of  the  pharynx,  which  origi- 
nates but  a  few  centimeters  further  back,  also  attacks  very 
young  subjects  in  considerable  frequency,  but  is  highly  malig- 

13 


194  CANCER 

nant  in  these,  as  in  theory  it  should  be.  Examples  like  these 
show  that  cancer  in  a  given  locality  is  apt  to  be  a  law  to  itself. 

As  already  stated,  in  familial  cancer  some  of  the  victims  are 
unusually  young,  and  unusual  localities  may  be  attacked  as  well 
as  the  ones  commonly  seen.  Cancer  among  the  Hindoos  and 
other  peoples  of  the  far  East  appears  to  develop  much  earlier 
on  the  average  than  cancer  in  the  Europeans;  this  may  be  due 
in  part  to  earlier  maturity  and  decline,  but  the  chief  factor, 
as  regards  the  disease  in  the  mouth,  is  doutedless  the  custom 
of  betal  leaf  chewing  which  is  begun  in  childhood. 

The  paradoxical  fact  that  a  young  subject  cannot  as  a  rule 
put  up  a  defence  against  cancer,  while  an  old  and  decrepit  one 
makes  a  vigorous  defence,  is  hard  to  reconcile  with  the  other 
fact  that  cancer  develops  more  frequently  in  the  old  subject,  and 
until  recently  has  hardly  been  associated  in  the  mind  with  the 
age  of  growth  and  development.  If  we  compare  cancer  to  a 
fungus  growth  in  a  special  type  of  soil,  then  it  should  attain  its 
greatest  development  in  the  soil  in  which  it  naturally  grows. 
Most  diseases  follow  this  law  but  cancer  is  an  exception,  and 
leads  to  the  conclusion  that  the  nature  of  cancer  in  the  young 
must  be  different  from  that  in  the  old.  Yet  as  we  have  just 
seen,  cancer  may  in  at  least  one  locality  be  milder  in  youth  and 
attain  its  greatest  malignancy  in  old  age. 

In  regard  to  immunity  of  certain  organs  several  questions  at 
once  come  up.  One  deals  with  the  existence  of  serum  immu- 
nity, which  has  been  vigorously  denied,  although  many  speak 
of  it  as  present  in  a  feeble  and  inconsistent  way,  quite  unequal 
for  diagnostic  and  therapeutic  usefulness.  Our  knowledge  of 
the  blood  in  cancer  subjects  in  which  the  disease  is  quiescent 
or  just  beginning  is  not  extensive,  and  can  hardly  be  detached 
from  the  study  of  blood  states  due  to  cancer.  Thus  the  blood 
state  in  cancer  had  best  be  studied  of  itself  from  all  angles. 

To  return  to  special  organ  immunity  and  susceptibility,  this 
has  been  denied  outright  by  F.  C.  Wood,  and  others.  That  one 
organ  is  frequently  attacked  while  another  is  usually  spared, 
is  capable  of  other  explanations  than  special  susceptibility  or 


NOSOLOGY  AND  RELATIONS  OF  CANCER  195 

immunity.  The  chief  support  of  the  negative  viewpoint  is 
seen  in  metastasis,  for  the  very  organs  which  escape  primary 
cancer  are  the  ones  which  are  most  likely  to  be  affected  by 
secondary  cancer,  and  vice  versa.  Furthermore,  carcinoma 
invades  all  tissues  impartially  which  are  contiguous  to  it,  this 
fact  showing  that  no  tissue  is  actually  immune.  The  liver  is 
seldom  the  seat  of  primary  cancer,  but  one  of  the  chief  victims 
of  secondary  and  metastatic  cancer.  The  apparent  immunity 
of  the  spleen  to  metastases  is  explained  by  Wood  through  the 
peculiarities  of  its  blood  supply,  which,  however,  permit  of 
metastases  of  sarcoma. 

Nevertheless  there  is  apparent  organ  immunity  and  numer- 
ous generalisations  have  been  based  on  it.  Cancer,  for  example, 
is  much  more  apt  to  develop  where  the  reaction  is  acid,  or  at 
least  naturally  so;  as  in  the  stomach  and  colon,  and  little  liable 
to  appear  where  the  reaction  is  normally  alkaline,  as  in  the 
duodenum.  Its  failure  to  appear  primarily  in  certain  organs 
is  readily  explained  by  the  absence  of  epithelium,  but  this  fact 
can  hardly  be  counted  under  immunity.  Cancer  is  said  to 
develop  where  there  is  an  abundant  supply  of  lymphatics, 
but  this  anatomical  fact  bears  chiefly  on  the  subject  of  secondary 
diffusion.  Other  generalisations  appply  to  the  alleged  presence 
of  bacterial  activity  and  decomposition,  etc.,  which  does  not 
agree  with  the  facts  and  is  lacking  in  lucidity. 

In  regard  to  organ  incidence  it  would  be  of  great  interest  to 
know  whether  cancer  is  increasing  in  all  localities,  or  only  in 
a  few  of  the  organs  which  bear  the  brunt  of  the  incidence.  As 
long  as  the  stomach  and  the  female  breast  and  uterus  furnish 
the  majority  of  cancers  it  seems  perverse  not  to  speak  of 
susceptibility  and  immunity.  If  we  turn  to  some  of  the  primi- 
tive folk  we  may  find  the  breast  and  uterus  almost  exempt, 
while  some  other  organ  like  the  buccal  cavity  or  penis  may 
head  the  list.  Even  in  some  civilized  countries,  as  Sweden, 
the  stomach  or  entire  alimentary  tract  may  furnish  the  majority 
of  cases,  while  both  uterus  and  breast  are  in  a  decided  minority. 
This  arbitrary  way  of  choosing  one  organ  in  one  part  of  the 


iq6  CANCER 

world  and  another  in  another  region  argues  either  for  a  special 
causal  nexus  for  each  kind  of  tumor,  or  for  a  general  condition 
that  selects  a  point  of  minimum  resistance. 

In  some  forms  of  cancer  the  exciting  cause  is  everything  and 
it  is  easy  to  abolish  these  types,  as  in  chimney  sweeps'  cancer, 
which  was  once  very  frequent,  even  heading  the  lists  in  some 
of  the  old  English  hospital  material.  It  has  been  practically 
stamped  out  by  legislation  and  improvements  in  construction. 
Betel  chewing  cancer  could  be  stamped  out  in  the  same  way,  as 
could  also  smoker's  cancer.  But  buccal  cancer  and  cancer  of 
the  scrotum  still  occur  in  the  absence  of  these  causal  factors.  In 
such  cases  we  cannot  make  use  of  the  term  local  immunity  and 
susceptibility.  It  is  probable  that  cancer  could  be  made  to 
appear  in  almost  any  locality  in  one  inclined  thereto  by  the 
blood  condition,  if  there  were  a  sufficient  amount  of  chronic 
irritation  applied,  although,  it  is  quite  certain  that  some 
localities  would  prove  more  resistant  than  others.  In  the 
absence  of  knowledge  of  predisposing  and  exciting  factors  we 
cannot  explain  the  increase  in  the  incidence  of  regional  cancers. 
Either  of  the  two  factors  might  increase  while  the  other  remains 
in  equilibrium.  This  subject  leads  naturally  to  the  local  fac- 
tors in  cancer. 

Local  Factors. — These  include  pre-cancerous  affections  and 
traumatism.  They  are  both  discussed  very  fully  in  textbooks 
and  we  shall  not  go  exhaustively  into  the  subject,  for  it  is 
evident  that  cancer  which  originates  in  a  lesion  of  any  sort  or 
from  any  form  of  injury  or  chronic  irritation  tends  to  in- 
crease or  diminish  with  the  exciting  cause.  Such  cancers 
are  readily  preventable  if  the  cause  can  be  removed,  and  do 
not  enter  into  the  general  problem  of  cancer  as  a  racial  malady. 
Moreover,  most  of  these  traumatic  cancers,  as  well  as  those 
which  originate  in  preexisting  lesions,  are  of  a  special  histological 
and  clinical  type,  and  many  are  of  low  malignancy,  with  little 
tendency  to  metastasize,  as  in  basal  cell  cancer.  Of  pre- 
cancerous conditions  we  may  name  benign  growths  of  various 
kinds  including  congenital  nevi,  any  form  of  ulceration  (chronic), 


NOSOLOGY  AND  RELATIONS  OF  CANCER  197 

low  forms  of  inflammation,  demonstrable  perhaps  only  under 
the  microscope,  among  which  belong  superficial  glossitis,  leuco- 
plakia  buccalis  and  analogous  lesions  on  the  genitals,  burns, 
scars,  and  dermatitis  with  hyperkeratosis  following  chronic 
irritation,  etc. 

Of  the  severe  and  malignant  types  of  internal  cancer  the 
mammary  form  is  preceded  by  adenoma  and  mastitis,  gastric 
cancer  by  round  ulcer,  prostatic  cancer  by  hypertrophic  pros- 
tate (technically  an  adenoma),  cancer  of  the  cervix  by  lacera- 
tion and  its  consequences,  etc.  These  of  course  explain  only 
part  of  the  morbidity.  Cancer  of  the  colon  has  no  such  distinct 
factors  to  account  for  its  presence,  and  this  seems  true  of  cancer 
of  the  oesophagus.  Nor  are  these  factors  always  lucid.  It 
does  not  increase  our  practical  knowledge  to  be  told  that 
cancer  of  the  breast  is  practically  always  preceded  by  evidence 
of  mastitis;  and  concerning  the  development  of  cancer  from 
benign  tumors  and  leukoplakia,  it  is  very  difficult  to  prove 
just  when  a  malignant  metamorphosis  has  really  occurred, 
for  a  papillomatous  cancer  may  at  its  origin  be  indistinguish- 
able from  benign  papilloma.  Some  25  or  30  types  of  cancer 
originating  in  other  lesions  have  been  isolated. 

The  evidence  of  trauma  as  a  factor  in  cancer  is  largely  of  the 
negative  type.  Before  the  cancer  age  so-called,  cancer  follow- 
ing traumatism  is  very  hard  to  prove,  and  in  the  recent  war,  of 
200,000  soldiers  in  the  French  army  either  dead  or  mustered  out 
at  a  given  period,  less  than  500  developed  cancer  and  not  one 
of  these  was  due  to  a  wound.  Of  the  500  cases  179  occurred  in 
soldiers  between  40  and  45,  and  most  of  these  were  cancers  of 
the  stomach.  The  only  organ  in  which  a  blow  is  repeatedly 
accused  of  causing  cancer  is  the  female  breast.  On  the  other 
hand  sarcoma  often  follows  a  single  blow,  fracture,  etc. 

Certain  substances  of  very  different  kinds  are  known  or 
believed  to  be  able  to  stimulate  the  multiplication  of  cells, 
including  cancer  cells,  just  as  others  are  believed  to  inhibit 
this  growth.  So-called  oncotropic  substances,  which  have  a 
selective   action   on   cancer   cells,   especially   staining   agents, 


198  CANCER 

conceivably  belong  here,  and  while  some  are  accused  of  stimu- 
lating, others  appear  to  inhibit  the  growth  of  the  cells.  Some 
agencies  like  x-rays  and  radium  stimulate  in  small  doses,  and 
inhibit  in  large  doses.  It  is  admitted  that  to  stimulate  cell 
growth  it  is  necessary  for  the  active  substance  to  enter  within 
the  cell,  where  it  can  disturb  karokinesis,  but  it  is  not  certain 
that  an  inhibiting  agent  must  have  this  property,  although  it 
doubtless  acts  directly  in  some  instances.  Among  substances 
said  to  excite  cell  growth  are  cholesterol,  potassium  salts, 
pituitrin,  indol,  and  skatol,  stains  like  trypan  and  sudan  red, 
also  many  active  substances  which  have  caused  occupation 
cancers,  like  aniline,  tar,  paraffin,  tobacco,  betel  nut,  leaf 
(really  calcium  in  admixture),  and  arsenic  in  internal  administra- 
tion (it  must  first  cause  hyperkeratosis)  and  others.  The 
katabolic  or  excretory  products  of  the  larvae  of  certain  nema- 
tode worms  are  known  to  produce  cancer  in  frogs  and  even  in 
warm-blooded  animals  (mice). 

In  addition  to  many  facts  there  is  a  world  of  speculation  on 
this  subject,  with  attempts  to  show  that  certain  cellular  pro- 
ducts of  a  katabolic  origin  act  as  manures  or  fertilizers  or 
catalysts  or  what  not,  and  thus  stimulate  cell  growth.  Certain 
cells  are  accused  of  fertilising  other  cells  and  thus  producing  a 
cancer  cell  brood.  Cancer  soil,  so-called,  has  been  likened  to 
a  vegetable  mold  in  which  cancer  grows  like  a  fungus.  There 
is  no  proof  of  these  claims,  but  there  are  many  facts  which 
suggest  that  cancer  is  at  least  favored  by  the  presence  of  certain 
catabolic  substances.  As  a  source  of  enzyme  or  hormone-like 
bodies  which  have  fertilised  cancer-genetic  cells,  lymphocytes 
have  been  accused,  as  well  as  spermatozoa-like  bodies. 

In  this  connection  should  be  mentioned  the  parasitic  theory. 
As  a  universal  cause  this  has  doubtless  been  eliminated,  but  no 
one  can  disprove  the  possibility  of  incidental  cancers  of  para- 
sitic origin.  This  has  been  shown  in  regard  to  tumor  growth  in 
plants,  and  there  is  no  reason  to  doubt  that  certain  bacteria  or 
protozoa  may  be  able  to  stimulate  cell  growth  in  animal  cells. 
The  so-called  symbiotes-bacteria,  believed  to  enter  the  tissue 


NOSOLOGY  AND  RELATIONS  OF  CANCER  199 

cells  and  promote  normal  functioning,  may  have  their  patho- 
genic counterparts.  These  as  yet  little  known  organisms,  even 
the  existence  of  which  has  not  yet  been  shown  beyond  doubt, 
have  been  associated  with  the  other  unknown  substances, 
vitamines — for  we  cannot  prove  that  vitamines  of  the  kind 
destroyed  by  heat  are  not  living  beings. 

Of  substances  known  to  inhibit  cell  growth  are  some  of  the 
amino-acids,  including  those  produced  by  the  normal  meta- 
bolism of  the  cell,  and  in  general  tryptophan  and  tyrosin, 
calcium  salts,  trypsin  (which  digests  cancer  protein),  the 
toxin  of  erysipelas,  radium  and  x-rays,  elevation  of  temperature 
in  mice  experiments,  etc.  In  this  class  are  to  be  placed  also  eosin, 
selenium,  uranium  salts  and  silica  (as  recommended  by  Czerny), 
Whatever  can  produce  a  fibro-plastic  reaction  is  indirectly  a  cell 
inhibitor. 

One  who  studies  this  chapter,  in  which  an  attempt  has  been 
made  to  present  some  of  the  observations  and  thoughts  of  the 
many  who  have  been  studying  "the  cancer  problem,"  must  be 
struck  both  with  the  difficulty  of  the  task,  and  the  almost 
hopelessness  of  trying  to  come  to  any  definite  conclusion  in 
regard  to  the  real  cause  of  carcinoma.  If  one  should  seriously 
heed  all  the  ideas  which  have  been  presented,  and  attempt  to 
act  upon  them  in  caring  for  cancer,  he  would  be  puzzled  indeed. 
The  writer  cannot  see  much  in  them  which  would  help  in  deter- 
mining any  intelligent  line  of  treatment.  Everything  seems  to 
point  to  the  conclusion  that  cells  are  only  degenerated  normal 
body  cells,  which  take  on  their  abnormal  action  from  a  wrong 
pabulum,  much  as  we  found  in  the  chapter  on  the  histo-patho- 
logy  and  in  that  on  the  bio-chemistry  of  cancer. 

We  found  that  the  energy  of  growth  of  malignant  disease 
had  often  been  compared  with  that  of  the  embryo,  only  that  of 
the  latter  was  superior. 

We  found  that  the  epithelial  cells  of  the  body  were  very 
active  entities,  which  were  constantly  changing  and  disap- 
pearing, as   their  proper  function    had   been  discharged;  but 


200  CANCER 

that  when  they  became  malignant  they  could  serve  no  useful 
purpose,  as  secretion,  etc.,  and  with  their  acquired  property  of 
malignancy  they  ran  riot,  as  it  were,  infecting  other  cells  and 
simply  dying  and  acting  as  a  foreign  body  on  which  the  ordinary 
forces  of  catabolism  and  anabolism  could  not  well  act. 

We  found  that  benign  and  malignant  neoplasms  did  not 
differ,  so  greatly  in  their  mechanism,  but  mainly  in  their  be- 
havior. Both  seemed  to  be  autonomous  and  independent  of 
the  laws  which  regulate  the  individual. 

Inflammation  was  found  to  be  closely  related  to  both.  Sar- 
coma seemed  to  have  somewhat  different  laws  from  carcinoma. 

We  found  that  cancer  had  certain  relations  to  constitutional 
diseases  of  various  kinds,  which  are  on  the  steady  increase 
among  civilized  people.  It  has  also  probably  relations  with 
the  endocrinous  glands. 

Cancer  was  found  to  be  a  disease  of  the  individual,  and  that 
heredity  played  little  or  no  part  in  its  genesis. 

While  along  certain  lines  immunity  and  susceptibility  seem 
to  be  an  element  in  the  situation  of  the  local  product  of  the 
disease  cancer,  nothing  can  be  learned  from  the  study  of  these 
features  which  helps  in  the  knowledge  or  treatment  of  cancer. 
Except  that  the  disease  is  peculiarly  liable  to  develop  in  locali- 
ties where  there  is  an  acid  reaction,  as  in  the  stomach  and  colon, 
which  sustains  the  theory  and  observation  that  cancer  is  in 
reality  an  acidosis  disease. 

We  see  thus  that  all  evidence  points  to  the  constitutional 
nature  of  the  disease,  which  slowly  develops  long  before  any 
local  manifestation  of  it  can  be  determined  with  certainty. 

All  of  which  leads  to  the  conclusion  which  even  many  sur- 
geons state  in  their  writings,  that  the  surgical  removal  of  a 
cancer  mass  does  not  and  cannot  cure  the  disease  or  insure  that 
there  shall  not  be  a  recrudescence  of  the  same. 


CHAPTER   XIII 
RELATION  OF  DIET  TO  CANCER 

For  the  proper  understanding  of  the  relation  of  food  and  drink 
to  cancer,  and  the  satisfactory  application  of  the  principles 
involved,  it  is  necessary  to  bear  well  in  mind  the  chemistry  of 
the  body,  and  the  relation  to  nutrition  of  the  various  elements 
which  contribute  to  form  its  tissues  and  cells,  both  in  health  and 
disease. 

The  human  body  is  composed  of  some  15  different  primary 
elements,  which  are  found  in  the  composition  of  what  enters  the 
mouth  and  lungs.  It  is  understood,  of  course,  that  all  food  is 
ultimately  broken  up  into  its  composite  organic  elements,  which 
are  carried  by  the  blood  and  appropiated  by  the  cells  for  their 
formation  and  nourishment,  and  to  enable  them  to  perform 
their  functions. 

Cancer  has  its  foundation  in  the  erroneous  formation  of  pre- 
viously healthy  cells.  Throughout  all  nature  it  is  recognized 
that  plants  and  animals  must  have  the  right  food  in  order  to 
have  healthy  and  vigorous  life,  and  man  is  no  exception.  There 
must  be  the  proper  balance  in  the  various  elements  of  nutriment, 
which  ordinarily  is  found  in  their  surroundings,  or  is  supplied 
by  human  intelligence.  Wild  animals,  guided  by  instinct,  select 
their  proper  food,  and  are  never  sick,  but  with  man  matters  are 
different.  He  does  not  seem  to  be  guided  so  much  by  instinct 
as  by  taste,  whim,  or  fancy,  or  by  the  influence  of  others,  and 
so  will  often  indulge  in  gratifying  the  taste  rather  than  simply 
in  satisfying  the  appetite,  and  the  temptations  to  this,  in  modern 
life,  are  increasingly  great.  Thus  it  happens  that  gross  errors 
are  continually  committed,  leading  to  various  diseases,  as  we  all 
know.  It  is  to  be  remembered  also  than  man  is  the  only  animal 
that  cooks  its  food,  or  attempts  to  alter  or  refine  it  from  its 


202  CANCER 

natural  state,  often  very  disadvantageously,  as  will  be  seen 
later. 

The  following  table,  from  Sherman,1  represents  probably  as 
approximately  correct  an  average  of  the  elements  composing  the 
human  body  as  can  be  given. 

Composition  of  the  Human  Body 

Oxygen About  65 .  00  per  cent 

Carbon About  18.00  per  cent 

Hydrogen About  10.00  per  cent 

Nitrogen About    3.00  per  cent 

Calcium About    2 .00  per  cent 

Phosphorus About    1 .  00  per  cent 

Potassium About    0.35  per  cent 

Sulphur About    o .  25  per  cent 

Sodium About    0.15  per  cent 

Chlorine About    0.15  per  cent 

Magnesium About    0.05  per  cent 

Iron About    o .  004  per  cent 

Iodine 

Fluorine \  Very  minute  quantities 

Silicon 

Sherman  says:  "The  so-called  inorganic  elements  exist  in  the 
body  and  take  part  in  its  functions  in  at  least  three  different 
ways:  1.  As  the  constituents  which  give  rigidity  and  compara- 
tive permanence  to  the  skeleton:  2.  As  essential  elements  of  the 
protoplasm  of  the  active  tissues:  3.  As  salts  held  in  solution  in 
the  fluids  of  the  body,  giving  these  fluids  their  characteristic 
influence  upon  the  elasticity  and  irritability  of  muscle  and  nerve, 
supplying  the  material  for  the  acidity  or  alkalinity  of  the  diges- 
tive juices  and  other  secretions,  and  yet  maintaining  the  neutral- 
ity or  slight  alkalenence  of  the  internal  fluids,  as  well  as  their 
osmotic  pressure  and  solvent  power." 

It  would  lead  us  too  far  from  the  practical  purposes  of  this 
writing  to  attempt  to  enter  into  the  chemistry  of  nutrition, 
which  is  a  most  interesting  study,  or  into  the  intricate  processes 
through  which  food  stuffs,   carbohydrates,   fats,   and  protein 

1  Sherman,  "Chemistry  of  Food  and  Nutrition."     New  York,  191 1,  p.  260. 


RELATION  OF  DIET  TO  CANCER  203 

substances,  pass  in  the  digestive  tract  before  they  are  broken 
up  into  their  component  parts  and  enter  the  blood.  But  for  the 
proper  understanding  of  the  relation  of  diet  to  cancer  these 
should  be  thoroughly  grasped,  as  shown  in  other  books.  The 
relation  of  the  organic  salts,  especially  calcium,  magnesium,  sod- 
ium, and  potassium  will  be  considered  later. 

The  actual  composition  of  the  body  is  changing  day  by  day, 
through  the  activities  of  the  system,  so  that  it  is  commonly 
believed  that  after  some  years  all  the  tissues  are  entirely  re- 
newed, and  the  entire  body  is  composed  of  new  materials.  The 
supplies  for  this,  for  the  daily  wear  and  tear,  and  that  expended 
in  heat  and  activity,  must  be  supplied  by  the  diet,  together  with 
oxygen  through  the  lungs.  For  the  ordinary  requirements  of 
the  system,  in  health,  as  already  suggested,  the  appetite  serves 
as  a  proper  guide,  which  should  suffice  in  man,  as  in  wild  animals, 
to  preserve  the  balance  of  nutrition. 

But  man  has  also  the  power  to  gratify  the  taste,  which  must  be 
recognized  in  our  study  as  distinct  from  satisfying  the  appetite; 
and  the  refinements  of  civilization  have  added  so  greatly  to  the 
temptation  of  wrong  eating,  and  overeating  and  drinking,  as 
they  have  to  so  many  other  temptations,  that  it  is  questionable 
if  reason,  and  what  is  often  spoken  of  as  the  natural  instinct  for 
food,  can  be  trusted  in  mankind. 

It  is  to  be  remembered  that  the  advance  of  civilization,  and 
the  facilities  of  transportation  and  cold  storage,  have  brought 
from  far  and  near  an  innumerable  number  and  variety  of  arti- 
cles for  food  and  drink,  including  condiments,  which  bear  no 
relation  to  the  relatively  few  simple  articles  formerly  consumed. 
Even  the  fruits  which  we  eat  are  rarely  ripened  fully  by  nature, 
but  are  picked  more  or  less  green,  and  undergo  an  artificial 
ripening  without  the  action  of  the  sun,  which  in  reality  is  akin 
to  decay.  The  effect  of  cold  storage  must  also  in  some  measure 
alter  meat,  poultry,  eggs,  etc. 

In  the  combination  and  preparation  of  articles  of  food,  also, 
so-called  civilization  and  refinement  have  made  the  greatest 
departure  from  the  simple  life  of  the  aborigines,  who  are  largely 


204  CANCER 

free  from  cancer,  and  with  increasing  wealth  and  ease  through- 
out the  civilized  world,  more  and  more  individuals  are  sharing 
in  unnecessary  and  often  harmful  indulgences:  and  this  is 
especially  true  of  animal  food,  the  consumption  of  which  has 
increased  so  greatly  of  late,  as  will  be  considered  further  on. 

Many  other  elements  likewise  enter  into  the  matter  of  the 
digestibility  and  consequent  nutritive  value  of  food  and  drink. 
Such  as  nervous  conditions,  rapid  eating,  imperfect  mastication, 
heat  and  cold,  character  of  the  air  breathed,  micro-organisms, 
etc.,  and  all  the  various  causes  which  may  derange  the  action 
of  the  digestive  organs,  and  so  prevent  the  perfect  metabolism 
between  nutrient  material  and  the  cells  composing  the  different 
organs  and  portions  of  the  human  frame. 

The  organic  substances,  protein,  carbohydrates,  and  fats, 
which  supply  the  nutrition  of  man,  are  found  in  various  com- 
binations in  animal  and  vegetarian  foods,  which  as  a  rule 
contain  much  of  the  organic  or  mineral  substances  necessary 
for  the  system:  all  of  these,  with  water  and  its  salts,  and  oxygen, 
supplied  by  the  lungs,  unite  through  anabolism  and  catabolism, 
to  build  and  maintain  the  human  body  in  health. 

It  is  well  known  that  in  order  to  preserve  health  and  proper 
weight  there  must  exist  in  the  economy  a  certain  balance  or 
equilibrium  between  the  amount  of  the  ingesta  and  the  excreta. 
Thus  we  speak  of  a  nitrogen  equilibrium,  a  carbo-equilibrium, 
a  phosphorus  equilibrium,  an  iron  equilibrium,  etc.,  some  of 
which  are  disturbed  continually  in  ill  health  and  in  different 
diseases,  including  cancer.  Thus  we  have  the  carbohydrate 
equilibrium  disturbed  in  diabetes,  the  carbohydrates  and  fats 
in  adiposis,  and  proteins  in  gout,  etc. 

Until  quite  recently  the  principles  of  diet  (even  if  not  often 
carried  out  in  practice)  have  been  established  on  lines  laid 
down  by  Carl  Voit,  of  Munich.  This  eminent  physiologist, 
after  observing  and  studying  the  actual  dietary  of  various 
classes  of  workers,  claimed  that  the  adult  man  of  1501b.,  doing 
moderate  muscular  work,  requires  118  gms.  of  protein,  or  al- 
buminous food,  56  gms.  of  fat,  and  500  gms.  of  carbohydrate,  with 


RELATION  OF  DIET  TO  CANCER  205 

a  total  fuel  value  of  3,000  Cal.,  in  order  to  maintain  the  body 
in  equilibrium. 

But  the  remarkable  and  scientific  experiments  of  Chittenden1 
have  demonstrated  beyond  question  that  perfect  bodily  and 
nitrogenous  equilibrium  can  be  maintained  with  one-third  of 
the  amount  of  protein  called  for  by  the  Voit  standards,  and 
with  a  total  value  in  the  diet  of  only  about  1,600  Cal.,  or  about 
one-half  of  that  indicated  as  necessary  by  Voit.  These 
experiments  were  based  on  a  group  of  five  men,  of  varying  age, 
professors  and  instructors  of  Yale,  13  volunteers  from  the 
Hospital  Corps  of  the  United  States  Army,  and  eight  students 
in  Yale,  all  thoroughly  trained  athletes,  26  in  all. 

It  would  be  quite  beyond  the  scope  of  this  writing  to  enter  at 
all  in  to  the  intricate  questions  connected  with  the  metabolism 
of  nitrogenous  and  other  food,  but  Chittenden  has  well  put 
the  reasons,  "Why  prominence  is  given  to  the  establishment  of 
nitrogenous  equilibrium  and  why  the  proteid  intake  assumes 
a  greater  importance  than  the  daily  amount  of  fats  and  carbo- 
hydrates consumed?  Fats  and  carbohydrates  when  oxidized 
in  the  body  are  ultimately  turned  into  simple  gaseous  products, 
namely  carbonic  acid  and  water.  Hence,  these  waste  products 
are  easily  and  quickly  eliminated,  and  cannot  exercise  much 
deleterious  influence,  even  when  formed  in  excess.  To  be 
sure,  there  is  waste  of  energy  in  digesting,  absorbing,  and 
oxidizing  the  fats,  and  carbohydrates,  when  they  are  taken  in 
excessive  amounts.  Once  introduced  into  the  alimentary 
canal  they  must  be  digested,  otherwise  they  will  clog  the 
intestines  or  undergo  fermentation,  and  so  cause  trouble. 
Further,  when  absorbed,  they  may  be  transposed  into  fat  and 
be  deposited  in  the  various  tissues  and  organs  of  the  body;  a 
process  desirable  up  to  a  certain  point,  but  undesirable  when 
such  an  accumulation  renders  the  body  gross  and  un wieldly. 

"With  proteid  foods,  on  the  other  hand,  the  story  is  quite 
different.  These  substances,  when  oxidized  yield  a  row  of 
crystalline  nitrogenous  products  which  ultimately  pass  out  of 
1  Chittenden,  "Physiological  Economy  in  Nutrition."     New  York,  1904. 


206  CANCER 

the  body  through  the  kidneys.  Prior  to  their  excretion,  how- 
ever, these  products — frequently  spoken  of  as  toxins — float 
about  through  the  body  and  may  exercise  more  or  less  of  a 
deleterious  influence  upon  the  system,  or,  being  temporarily 
deposited,  may  exert  some  specific  or  local  influence  that  calls 
for  their  speedy  removal.  Hence  the  importance  of  restrict- 
ing the  production  of  these  bodies  to  the  minimal  amount, 
owing  to  their  possible  physiological  effect,  and  the  part  they 
are  liable  to  play  in  the  causation  of  many  diseased  condi- 
tions.'' We  have  seen  in  the  preceding  chapters  on  the 
biochemistry  of  cancer,  and  metabolism,  how  constantly  a 
deranged  nitrogenous  partition  occurs  in  this  disease. 

When  we  consider  the  small  share  which  nitrogen  plays  in 
the  normal  human  frame,  only  3  per  cent,  as  shown  in  the  table 
just  presented,  it  is  easy  to  see  how  an  excess  of  nitrogenous 
food  must  necessarily  either  pass  off  unassimilated  or  undergo 
imperfect  cleavage  into  its  ultimate  elements,  and  so  derange 
the  general  metabolism.  Chalmers  Watson,1  and  others,  have 
shown  in  a  most  remarkable  manner,  by  animal  experiments, 
that  an  excessive  meat  diet  alters  very  materially  the  micro- 
scopic structure  of  the  cells  of  very  many  organs  and  portions 
of  the  body. 

Beneke,2  who  is  often  quoted,  was  one  of  the  first  to  seri- 
ously consider  the  actual  diet  beneficial  in  cancer,  his  obser- 
vations dating  back  to  1875,  upon  material  in  the  service 
of  Esmarch  and  Oldekop,  who  treated  patients  according  to 
his  plan.  While  the  diet  he  gave  was  not  wholly  vegetarian, 
he  limited  the  nitrogenous  intake  very  greatly  and  reported 
some  very  favorable  results,  with  the  complete  disappearance 
of  some  malignant  new  formations. 

Referring  now  to  data  presented  in  a  previous  chapter 
concerning  the  frequency  and  geographical  distribution  of 
cancer,  we  can  understand  better,  on  scientific  grounds,  some 
of  the  reasons  why  the  disease  is  so  steadily  increasing  in 

1  Watson,  "Food  and  Feeding  in  Health  and  Disease."     New  York,  1913. 

2  Beneke,  Berlin.   Klin.  Wochenschr.,  March  15, 1880. 


RELATION  OF  DIET  TO  CANCER  207 

civilized  communities,  and  why  in  some  sections  of  the  earth  it 
is  less  common,  while  certain  aborigines  have  seemed  to  be 
almost  immune. 

In  England  vital  and  other  statistics  have  received  very 
much  attention  for  many  years,  dating  back  to  1840,  when  under 
the  able  direction  of  William  Farr,  they  had  acquired  a  well- 
deserved  reputation  for  reliability.  In  England,  a  few  years 
ago,  it  was  stated  that  the  consumption  of  what  was  called 
butchers'  meat  had  risen  to  130  pounds  per  capita,  that  is  of 
the  total  population,  men,  women  and  children,  in  addition  to 
large  quantities  of  fish,  game,  poultry,  rabbits,  eggs,  cheese, 
etc.  Among  the  well-to-do  the  meat  consumption  has  been 
estimated  at  between  180  and  330  lb.  per  year.  All  this  is 
much  more  than  double  the  amount  consumed  50  years  ago,  and 
in  the  same  time  deaths  from  cancer  have  increased  four  fold. 

In  Ireland,  where  the  meat  consumption  in  1895  was  only 
40  lb.  per  capita,  or  less  than  one-third  that  in  England,  the 
cancer  death  rate  is  very  much  lower,  not  much  over  one-half: 
and  yet  the  average  age  of  the  population  is  very  high,  as  the 
young  people  emigrate  and  the  older  ones  stay  in  the  country. 

In  the  United  States  the  mortality  from  cancer  has  certainly 
risen  very  greatly  during  the  last  50  years,  and  the  consumption 
of  meat  has  also  increased  very  largely.  In  1909,  the  per  capita 
amount  was  215.9  iD-  Per  capita,  which,  however,  had  fallen 
to  20 1. 1  lb.  in  1909,  in  which  year  the  cancer  death  rate 
was  73.8  persons  per  100,000  living:  then  in  1914,  it  was  79.4, 
and  in  1915,  81. 1  persons  per  100,000. 

The  United  States  Report  of  the  Meat  Situation,  191 6, 
furnishes  some  valuable  information  to  aid  in  this  inquiry. 
According  to  this  I  learn  that  the  consumption  of  meat  had 
recently  reached  the  enormous  amount  of  172  lb.  per  capita 
yearly,  a  quantity  much  greater  than  in  England. 

The  Argentine  Republic  stands  next  to  England  in  the  con- 
sumption of  meat  with  140  lb.  per  capita  in  1899,  and  with  a 
cancer  mortality  of  91  per  100,000,  in  1900. 

New  Zealand  exceeds  the  United  States  a  little,  with  a  meat 


208  CANCER 

consumption  of  212.5  lb.  per  capita  in  1902,  and  an  increase  in 
cancer  mortality  from  32  in  1877-1888,  to  60  per  100,000  in 
1900,  and  71  in  1903.  This  increase  is  mainly  among  British 
and  other  residents,  whereas  the  aborigines,  living  simple  lives, 
are  reported  as  seldom  affected. 

Australia  stands  first  in  the  consumption  of  meat,  with  the 
enormous  rate  of  262.6  lb.  per  capita  in  1902,  and  the  increase 
of  deaths  from  cancer  is  most  striking.  In  1851  the  death  rate 
per  100,000  living,  was  14,  in  1900,  62.6,  and  in  1913,  75  per 
100,000  living.  The  most  striking  difference  is  exhibited 
between  those  who  are  native  born,  who  in  1900  had  a  cancer 
death  rate  of  only  22  per  100,000,  while  the  British  born  had  a 
mortality  from  cancer  of  203,  or  over  nine  times  as  great.  A 
still  higher  ratio  was  found  among  immigrants  of  some  other 
nationalities.  Those  who  have  written  there  on  the  subject 
ascribe  this  frightful  proclivity  to  cancer  to  the  gluttonous 
habits  of  the  immigrants,  who  have  meat  for  breakfast,  lunch, 
dinner,  tea,  and  supper.     (MacDonald,  Williams.) 

Italy,  consuming  the  least  quantity  of  meat,  46.5  lb.  per 
capita,  in  1901,  had  the  lowest  cancer  rate,  but  the  present  meat 
consumption  cannot  be  learned.  In  Italy,  however,  the 
mortality  from  this  disease  is  steadily  rising,  from  50.9,  per 
100,000  from  i860  to  1900,  to  63.6  per  100,00,  from  1906  to 
1910.  The  cities,  however,  where  travellers  bring  luxurious 
living,  show  a  very  high  death  rate  from  cancer.  In  191 2, 
Rome  had  99.6,  Genoa,  100.7  Turin,  n  1.6  Milan,  120.7,  and 
Florence,  165. 1  deaths  from  cancer  per  100,000  population. 
The  poorer  country  districts  must  have  a  very  low  cancer  death 
rate,  as  the  general  death  rate  in  191 2  from  cancer  in  Italy 
was  only  64.7,  in  spite  of  the  very  high  rate  in  populous  cities. 

Spain,  also,  with  a  very  low  meat  consumption,  49  lb.  per 
capita,  had  a  cancer  death  rate  of  only  55.5  persons  per  100,000 
living  in  191 2. 

But,  as  I  have  often  tried  to  show,  the  real  basic  cause  of 
neo-plastic  growths  is  due  to  some  one  or  many  derangements 
of  metabolism,  inducing  a  blood  current  which  does  not  properly 


RELATION  OF  DIET  TO  CANCER  209 

nutrify  the  body  cells,  and  that  derangement  is  not  necessarily 
due  to  any  one  single  cause,  as  meat  diet,  although  that  forms 
a  large  share  of  it,  and  with  that  wrong  all  else  is  wrong. 

There  are  other  elements  of  disturbance  besides  the  nitro- 
genous mal-assimilation  due  to  the  intake  of  an  excessive 
amount  of  proteid  from  the  animal  kingdom.  For  cancer  is 
said  to  have  been  seen  in  vegetarians,  although  I  have  never 
personally  known  of  such  a  case,  and  Dr.  Kellogg  of  the  Battle 
Creek  Sanitarium,  has  never  known  of  a  case  developing  in 
one  who  had  strictly  followed  their  regimen.  We  know, 
however,  that  some  of  the  articles  from  the  vegetable  kingdom, 
such  as  the  pulses  and  nuts,  contain  a  very  large  proportion  of 
proteid.  Thus,  dried  peas  contain  21  per  cent,  haricot  beans, 
23,  lentils  23.2,  dried  lima  beans  26.4,  soy  bean  flour  39.5, 
almonds  24,  peanuts  25.8,  black  walnuts  27.6,  and  butternuts 
27.9  per  cent  of  proteid,  all  of  them  more  than  is  found  in  beef 
and  mutton.  Thus  a  large  supply  of  any  of  these  might  cause 
the  same  nitrogenous  error  in  the  blood  stream  as  is  induced  by 
meat. 

We  see,  also,  that  the  system  can  secure  all  the  protein  needed 
for  its  cells  and  nuclei  from  the  vegetable  kingdom,  as  the 
animals  do,  and  somehow,  we  know  not  how,  vegetable  protein 
seems  less  obnoxious  to  nutrition  than  that  which  is  formed 
in  animal  life.  Much  vegetable  protein  is  also  found  in  many 
of  the  ordinary  vegetarian  foods,  which  give  the  following 
percentages  of  nitrogen,  according  to  the  Experimental  Station 
of  the  United  States  Department  of  Agriculture:  oat  meal  16. 1, 
macaroni  13.4;  Graham  flour  13.3;  cracked  wheat  n.i;  shred- 
ded wheat  10.5;  Zwiebach  9.8;  corn  meal  9.2;  hominy  8.3;  rice 
8;  potato  chips  6.8;  rye  flour  6.8;  buckwheat  flour  6.4;  most 
of  the  succulent  vegetables  contain  from  1  to  3  per  cent  of 
protein. 

Coffee  and  tea  are  so  widely  and  almost  universally  used  in 
civilized  countries,  and  their  apparently  pleasant  effect  is  so 
great  that  few  realize  that  harm  may  result  therefrom;  although 
from   time  to  time  their  injurious  effects,  especially  along  the 

14 


2IO  CANCER 

line  of  digestive  and  nervous  affections,  are  dwelt  upon  by  medi- 
cal writers.  In  my  own  person,  on  medical  advice,  I  have 
experienced  the  most  remarkable  result  in  the  immediate,  abso- 
lute, and  permanent  relief  of  an  obstinate  and  agonizing  spas- 
modic stomach  trouble,  solely  by  abandoning  coffee,  that  I  am 
more  than  ever  convinced  of  the  potency  of  coffee  in  creating 
systemic  disorder. 

Of  late  years  considerable  attention  has  been  paid  to  the 
influence  of  coffee  and  tea  on  metabolism,  and  to  the  increase  of 
cancer  thereby.  From  a  report  to  the  House  of  Commons,  in 
England,  Holland  is  shown  to  be  the  largest  consumer  of  coffee 
of  any  country  in  Europe,  and  the  cancer  rate  in  1905  was 
among  the  highest,  101  in  100,000.  Hungary  was  shown  to  be 
the  smallest  consumer  of  coffee,  and  the  cancer  mortality  in 
1903,  was  only  39  per  100,000,  or  a  little  over  one-third  of  that 
in  Holland.  It  may  be  interesting  to  know  that  Thompson1 
states  that:  "the  people  of  the  United  States  consume  one- 
third  of  the  coffee  produced,  or  more  than  Germany,  Austria, 
Hungary,  France  and  the  United  Kingdom  combined.  On  the 
other  hand,  England  and  her  colonies  consume  one-half  of  the 
world's  output  of  tea,  and  the  United  States  but  one-fifth  of  it." 

The  scientific  basis  of  a  possible  relationship  of  the  consump- 
tion of  coffee  and  tea  to  the  prevalence  of  cancer  may  be  better 
understood  when  we  remember  that  caffeine  and  theine  belong 
to  the  xanthin  group,  and  contain  exactly  the  same  equivalent 
of  nitrogen  as  uric  acid.  A  single  cup  of  coffee  of  fair  strength  is 
stated  by  Hutchinson2  to  contain  1.7  grains  of  caffeine,  and  a  cup 
of  tea,  1. 2 1  g.,  so  that  when  indulged  in  largely  much  harm  may 
result;  also  the  latter  contains  an  amount  of  tannic  acid,  two 
or  three  times  greater  than  the  former.  It  is  readily  seen  that 
as  some  individuals  take  large  quantities  of  either  of  these,  much 
harm  can  be  done:  the  working  class  especially  often  consume 
enormous   amounts   of   tea,   which  is  kept  brewing   all   day. 

1  Thompson,  "Practical  Dietetics."     New  York,  1901,  p.  256. 
2 Hutchinson,  "Food  and  the  Principles  of  Dietetics."     New  York,  191  r,  p. 
324- 


RELATION  OF  DIET  TO  CANCER  2 1 1 

Roberts1  has  very  clearly  demonstrated,  by  clever  experiments, 
that  tea  interferes  greatly  with  the  salivary  and  gastric  digestion. 

Alcohol,  or  some  of  its  combinations,  has  also  been  shown  by 
several  observers  to  be  undoubtedly  an  element  contributory 
to  the  causation  of  cancer.  This  relates  not  only  to  countries 
or  cities  where  the  consumption  is  greatest  or  least,  but  also  to 
various  occupations,  in  which  statistics  show  the  more  or  less 
abundant  use  of  distilled  or  fermented  drinks,  and  increased 
deaths  from  the  same,  and  also  in  regard  to  fewer  deaths  among 
total  abstainers;  and  a  careful  study  of  the  subject  makes  it 
pretty  clear  that  the  incidence  of  cancer  corresponds  in  a  measure 
with  drinking  habits.  Cancer  mortality  is  highest  among 
those  classes  of  persons  among  whom  primary  or  secondary  mor- 
tality from  alcoholism  is  greatest. 

There  are  so  many  elements  to  be  taken  into  consideration  in 
connection  with  the  derangements  of  metabolism  which  lead  to 
cancer,  that  it  is  difficult  to  fix  upon  the  precise  influence  which 
each  may  exert.  But  in  watching  cancer  cases  for  any  length 
of  time  it  is  easy  to  see  the  harmful  effect  when  alcoholic  bever- 
ages are  indulged  in,  and  the  improvement  when  all  such  are 
absolutely  excluded. 

We  understand,  of  course,  that  the  body  is  a  vast  laboratory, 
wherein  by  exceedingly  complicated  processes,  material  from 
the  outside  world  is  appropriated  to  the  needs  of  the  economy, 
and  after  its  use  is  cast  out  in  very  different  and  elementary 
or  composite  forms.  To  effect  the  various  changes  necessary 
in  this  material,  we  have  a  very  considerable  number  of  what 
are  called  organs,  of  secretion  and  excertion,  whose  functions 
are  combined  in  a  marvellous  manner,  which  is  even  yet  very 
imperfectly  understood.  All  these  processes  seem  to  be  con- 
trolled and  co-ordinated  by  the  action  of  the  endocrinous  or 
ductless  glands,  of  which  we  know  still  less. 

The  actual  procedure  by  means  of  which  most  of  these  activi- 
ties are  carried  on  is  one  of  oxidation,  by  means  of  the  oxygen 
supplied  by  the  lungs,  which  constitutes  about  65  per  cent  of  the 

1  Roberts,  "Lectures  in  Dietetics  and  Digestion."    London,  1886. 


212  CANCER 

human  body.  Now  to  make  up  for  the  loss  of  the  other  14 
elements  which  form  35  per  cent  of  the  body  tissues,  and  to 
support  the  necessary  activities  of  the  system,  mental  and  physi- 
cal, it  is  necessary  every  day  to  take  in  a  more  or  less  evenly 
balanced  supply  of  outside  substances,  which  we  call  food  and 
drink,  and  these  should  contain  about  the  proper  proportion  of 
the  requisite  bodily  components.  It  is  easy  to  see,  therefore, 
how  quite  unconsciously,  through  carelessness,  errors  of  judg- 
ment, or  perverted  will,  the  system  may  be  deprived  of  some 
valuable  or  important  elements  necessary  to  supply  the  blood 
with  exactly  proper  material  for  the  cells,  constantly  changing 
by  catabolism  and  anabolism,  or  it  may  receive  too  great  a 
supply  of  some  particular  substance,  such  as  the  nitrogenous 
protein,  for  it  to  elaborate.  The  whole  problem  of  good  and 
bad  nutrition  is  so  intimately  connected  with  the  real  cancer 
problem  that  it  will  be  some  time  before  all  these  matters  are 
satisfactorily  worked  out.  But  labor  omnia  vincet,  and  it  is 
confidently  hoped  and  expected  that  extended  clinical  and  lab- 
oratory work  along  proper  lines,  quite  different  perhaps  from 
those  along  which  it  has  been  commonly  done,  will  ere  long 
throw  much  more  light  on  the  subject. 

The  difficulty  of  understanding  and  applying  our  present 
knowledge  of  nutrition  in  its  relation  to  cell  life,  normal  and 
abnormal,  is  well  illustrated  in  a  report  from  the  director  of  the 
Imperial  Cancer  Research  Fund,  as  editorially  commented  on 
recently  in  the  Lancet.1 

"Investigation  on  the  metabolism  of  cancer  cells,  their 
nutrition  requirements,  their  chemical  composition,  their 
respiration,  have  so  far  failed  to  reveal  any  features  in  which  the 
malignant  cell  is  essentially  different  from  a  normal  or  non- 
malignant  cell  ...  So  far  nothing  has  been  found  to  show 
that  the  mechanism  of  the  growth  is  in  any  way  different  from 
that  of  a  normal  cell.  In  many  respects  the  likeness  between 
the  cancer  cell  and  the  normal  cell,  of  the  animal  in  which  it 
originated,  is  greater  than  that  between  the  normal  cells  of 

1  Lancet,  July  31,  1920,  p.  254. 


RELATION  OF  DIET  TO  CANCER  213 

two  different  animals.  The  change  which  takes  place  when  a 
normal  cell  becomes  malignant  is  evidently  a  subtle  one,  and 
cannot  be  expressed  in  the  comparatively  crude  terms  of 
ferments,  toxins,  differences  in  amino-acids,  increased  affinity 
for  food  stuffs,  and  so  on.  The  nature  of  this  subtle  change 
cannot  be  stated,  and  the  disability  arises  from  the  fact  that 
our  knowledge  of  the  normal  cell  life  is  yet  imperfect,  while 
the  phenomena  of  growth  in  the  normal  cell  life  forms  almost 
a  terra  incognita." 

After  referring  to  the  mechanism  of  proliferation  of  cells  in  the 
reparation  of  damages  to  the  skin,  which  he  says  cannot  yet  be 
answered,  he  says,  "but  they  will  have  to  be  answered  before 
we  can  hope  to  understand  how  the  malignant  cells  begin  to 
proliferate  and  how  they  escape  the  control  which  keeps  in 
check  the  proliferation  of  the  normal  cell.  The  'cancer  prob- 
lem/ viewed  from  the  aspect,  is  a  biological  problem." 

We  see  here  again  that,  while  the  laboratory  is  the  foundation 
for  scientific  medicine,  its  powers  are  limited,  and,  as  in  the 
past,  we  must  more  or  less  fall  back  on  careful  observation, 
with  inductive  and  deductive  reasoning,  together  with  clinical 
and  other  experience,  if  we  would  be  successful  in  combatting 
cancer. 

An  interesting  confirmation  of  the  beneficial  results  of  a  low 
diet  and  simple  life,  as  regards  cancer,  is  found  in  certain  reports 
of  Commissioners  of  Prisons  and  Asylums  in  England,  where  the 
matter  has  been  studied,  as  given  by  Russell.1  Asylums  con- 
tain an  excessive  number  of  persons  who  have  inherited  or 
acquired  constitutional  weakness,  and  in  many  cases  tendencies 
towards  consumption  or  cancer:  also  many  alcoholics  who  are 
prone  to  these  maladies.  Yet  the  habits  and  rules  of  these 
institutions  reduce  the  cancer  rate  much  below  that  of  the 
classes  from  which  they  are  drawn,  and  below  the  rate  of  both 
occupied  and  unoccupied  persons." 

The  same  is  observed  in  regard  to  many  religious  orders, 
where  the  members  live  a  very  simple  and  frugal  life,  and  where 

1  Russell,  "Preventable  Cancer."    London,  1912,  p.  96. 


214  CANCER 

cancer  is  reported  to  be  almost  unknown.  Personally,  I  can 
recall  but  a  single  instance  among  such,  a  sister  of  pretty  high 
rank,  with  cancer  of  the  breast,  who,  I  think,  was  pretty  self 
indulgent,  although  I  have  had  very  many  men  and  women 
belonging  to  such  orders  under  my  care  for  other  troubles. 

Valuable  confirmation  of  the  relation  of  diet  to  neo-plastic 
growth  is  attributed  to  Ehrlich,  but  I  cannot  find  the  original 
reference.  He  "has  shown  that  mice  living  upon  a  rice  diet 
cannot  be  inoculated  with  cancer,  while  mice  living  on  a  meat 
diet  can  be  readily  inoculated,  cancerous  tumors  developing 
quickly  and  continuing  to  grow  until  the  animal  dies."  Ehrlich 
also  found  that  when  mice,  with  cancerous  tumors,  the  result  of 
inoculation,  were  placed  upon  a  rice  diet,  the  tumors  ceased  to 
grow,  and  in  many  cases  degenerated  and  disappeared.  This 
confirms  what  I  have  already  mentioned,  that  in  an  extensive 
trip  through  the  Far  East,  I  failed  to  find  any  cases  of  cancer, 
though  I  visited  many  hospitals  in  different  countries,  minister- 
ing to  millions  of  population,  and  was  repeatedly  told  by  intel- 
ligent physicians,  missionary,  civil,  and  military,  that  they  did 
not  have  cancer  among  rice-eating  peoples. 

This  is  further  confirmed  by  experiments  made  by  Sweet, 
Corson,  White,  and  Saxon.1  They  made  a  series  of  experiments 
on  the  "influence  of  certain  diets  upon  the  growth  of  experimen- 
tal tumors,"  all  with  the  same  results.  Of  50  white  mice,  25 
fed  on  glutenin  and  gliadin,  and  25  on  normal  diet,  23  of  the  25  on 
the  normal  diet  acquired  tumors,  against  only  4  in  the  25  on  glu- 
tenin and  gliadin.  This  was  repeated  on  50  males,  with  the  result 
of  18  in  25  against  3  in  25  of  the  latter  class:  and  in  a  third  series 
of  50  females,  the  figures  were  15  in  25,  against  7  in  25.  Thus, 
they  found  that  75  per  cent  of  75  mice  developed  experimentally 
inoculated  tumors  when  under  normal  diet,  while  only  19 
per  cent  of  other  75  mice  developed  such  tumors  when  under  a 
diet  of  glutenin  and  gliadin,  that  is,  vegetable  proteins.  More- 
over, the  tumors  in  the  latter  were  in  30  days  hardly  larger  than 

1  Sweet,  Corson,  White,  and  Saxon,  Proceed.  Soc.  for  Exper.  Biol,  and  Med., 
N.  Y.,  Vol.  x,  p.  175. 


RELATION  OF  DIET  TO  CANCER  2 1 5 

those  in  the  former  in  10  days.  Rous1  has  recently  shown  that 
large  growths  of  certain  rat  and  mouse  tumors  are  checked  in 
their  development  by  underfeeding  the  host  on  a  special  diet. 

Kessler2  has  called  attention  to  the  disturbance  of  sulphur 
partition  in  cancer  patients,  in  connection  with  diet,  and  the 
desirability  of  excluding  those  foods  exhibiting  an  excess  of 
sulphur,  giving  lists  of  the  same,  and  indicating  a  satisfactory 
diet. 

Packard3  has  made  a  strong  argument  in  regard  to  the  value 
and  importance  of  the  mineral  elements  contained  in  plant  life, 
in  connection  with  the  disturbances  in  the  elements  which  had 
been  observed  in  connection  with  cancer.  He  recalls  that 
modern  chemistry  teaches  that  the  organic  principles  of  the 
vegetable  kingdom  are  absolutely  necessary  to  the  highest 
degree  and  type  of  animal  tissue  and  health,  and  resistance  to 
disease.  Plant  life  is  the  connection  between  the  minerals  and 
salts  of  the  earth  and  animal  life,  but  in  the  manufacture  or 
refinement,  and  cooking,  of  products  of  the  vegetable  kingdom, 
and  many  of  them  are  largely  demineralized.  This  is  especially 
so  in  the  case  of  fine  white  wheat  flour,  rice,  potatoes  (in  peeling 
and  cooking)  etc.  So  that  while  animals  get  plenty  of  mineral 
matter  in  right  proportions,  from  plants  and  the  earth,  man  gets 
but  little,  and  while  the  herbiverous  animals  are  rarely  affected 
with  cancer,  civilized  man  is  succumbing  to  it  more  and  more 
every  year.  One  has  often  seen  animals  consume  earth,  and 
dogs  bury  bones  to  gnaw  on  later  when  they  have  absorbed 
minerals  from  the  earth.  The  United  States  Agricultural 
Department  informs  us  that  in  the  rough  peeling  of  potatoes, 
formerly  so  common,  and  in  the  soaking  and  boiling  them, 
fully  30  per  cent  (some  say  50  per  cent)  of  the  nutriment  was 
lost,  including  all  of  the  valuable  potassium  and  other  salts 
contained  in  the  inner  skin. 

It  is  stated  that  among  savage  tribes,  who  are  practically  free 

1Rous,  Journal  of  Ex  per int.  Med.,  Lancaster,  Perm.,  1914,  p.  433. 

2 Kessler,  New  York  Med.  Journal,  1912,  p.  122. 

3  Packard,  Boston  Med.  &  Surgical  Journal,  1912,  p.  452. 


216  CANCER 

from  cancer,  the  water  in  which  vegetables  are  cooked  is  also 
consumed  as  food,  thus  securing  all  the  salts.  It  has  long  been 
my  custom,  to  have  all  the  water  in  which  all  vegetables  are 
boiled  for  the  family,  used  as  the  stock  for  soup,  in  regard  to 
the  vegetable  soup  given  to  cancer  patients,  as  will  be  seen 
in  connection  with  the  diet  card  furnished,  as  described  in 
the  chapter  on  Diet  in  Cancer. 

The  same  idea  of  mineral  starvation  has  been  popularly 
presented  to  the  public  in  a  startling  manner  by  McCann1  in  a 
book,  which,  with  a  great  deal  of  verbiage,  contains  a  large 
amount  of  valuable  information  concerning  nutrition,  and  its 
disturbance  by  erroneous,  or  worse,  preparation  and  adminis- 
tration of  food. 

Possibly  there  are  other  dietary  elements  which  may  also 
play  some  part  in  the  causation  of  cancer,  but  the  demonstrated 
facts  concerning  them  are  so  few  and  uncertain  that  they  need 
not  detain  us  here,  although  it  is  certainly  desirable  to  investi- 
gate any  and  all  that  seem  to  have  reasonable  support.  And 
it  is  hoped  that  the  future  will  develop  many  more  facts 
which  will  aid  in  solving  more  clearly  the  real  cancer  problem. 

Some  of  these  which  have  been  suggested  probably  have  to  do 
with  a  local  irritant  action  on  the  digestive  organs,  as  we  have 
seen  that  prolonged  local  irritation  undoubtedly  plays  an 
important  part  in  the  determination  of  the  site  and  actual 
time  of  occurrence  of  cancerous  disease,  for  instance,  in  the 
mouth,  from  a  ragged  tooth,  etc.  Thus,  some  have  ascribed 
cancer  of  the  mouth,  palate,  oesophagus,  and  stomach  to  hot 
food  or  drink,  or  to  stimulating  drink,  condiments,  etc.,  and  it 
is  quite  possible  or  probable  that  they  act  as  the  exciting  cause, 
to  start  the  epithelial  cells  on  their  destructive  course,  when  the 
other  elements  are  favorable  to  such  development. 

The  increasing  frequency  of  cancer  in  the  mouth,  palate, 
oesophagus,  and  stomach  in  men,  especially,  looks  toward  an 
irritating  character  of  the  substances  which  traverse  these 
regions,  including  alcoholic  drinks,  and  the  irritant  effect   of 

1  McCann,  "Starving  America."     New  York,  1912. 


RELATION  OF  DIET  TO  CANCER  217 

tobacco  should  not  be  overlooked  in  regard  to  cancerous  mouth 
lesions.  But  of  the  millions  who  use  tobacco  only  very  few  are 
affected  with  cancer,  and  as  far  as  we  can  see,  only  those  pre- 
disposed thereto  by  some  metabolic  disturbance,  as  has  been 
previously  considered.  It  has  been  already  mentioned  that  I 
have  found  the  saliva  to  be  acid  almost  invariably  in  cancer 
patients,  even  in  those  with  early  disease,  and  I  think  I  have 
never  found  it  otherwise,  unless  altered  by  treatment,  in  those 
with  malignant  lesions  within  the  mouth.  With  this  there  is  a 
faulty  preparation  of  carbonaceous  and  fatty  foods. 

Mayo1  says:  "In  civilized  man  one-third  of  all  cancers  are 
seated  in  the  stomach.  This  is  not  known  to  be  the  case  in 
uncivilized  man,  or  in  animals.  There  should  therefore  be 
something — some  one  cause — which  causes  the  preponderance. 
The  acid  secretion  may  favor  its  development,  for  when  we 
come  to  the  colon,  also  with  an  acid  secretion,  we  again  meet 
with  cancer,  and  we  seldom  see  it  in  the  alkaline,  small  intestine. 
Gastric  ulcer,  which  may  be  pre-cancerous,  is  connected  with 
hyper-acidity. 

In  Scandanavia  cancer  of  the  stomach  is  remarkably  frequent, 
according  to  Soegaard;2  thus  of  1,235  cancer  cases  in  Norway, 
73.9  per  cent  were  in  that  location.  In  a  former  chapter  we 
saw  that  cancer  in  general  was  connected  with  a  lowered 
alkalescence  of  the  blood,  and  all  our  studies  show  hyper- 
acidity to  be  related  to  cancer  genesis.  Nitrogenous  acidity, 
or  uric  acid  (purim  bases,  xanthin,  etc.)  undoubtedly  plays  a 
great  part  in  inducing  malignant  action  in  tissues,  as  Haig3  has 
so  long  contended,  even  in  regard  to  cancer;  and  the  almost 
invariable  occurrence  of  rheumatic  and  neuritic  symptoms  in 
cancer  patients,  even  in  regions  far  distant  from  definite  lesions, 
shows  this  strongly.  Such  pains,  as  also  the  pains  in  active 
cancerous  lesions  are  continually  found  to  be  controlled  by 
efficient  repeated  administration  doses  of  aspirin,  which  also 
seems  to  help  the  cancer  itself. 

1Mayo,  "Annals  of  Surgery."     1014,  P-  587. 

J  Soegaard,  "Zeitschr.  fiir  Krebsforsch."     1913,  p.  89. 

3  Haig,  "Uric  Acid  in  the  Causation  of  Disease."     7th  edition,  1908,  p.  420. 


218  CANCER 

Although,  as  far  as  I  know,  there  are  no  scientific  observations 
to  prove  it,  still  I  cannot  help  feeling,  from  a  long  clinical  study 
of  cancer  as  a  disease,  that  xanthin  or  some  of  the  purin  bases, 
has  to  do  with  the  erroneous  and  erratic  action  of  the  cells 
which  result  in  cancer.  We  have  seen  in  a  previous  chapter 
how  the  cancer  cells  change  from  the  form  of  normal  cells, 
and  in  the  chapter  on  the  bio-chemistry  of  cancer,  that  there 
were  changes  in  their  chemical  constituents,  especially  in  regard 
to  the  nuclei  which  supply  the  endogenous  purin,  and  we  shall 
see  later  how  cutting  off  the  supply  of  exogenous  purin  checks 
the  disease.  We  know  of  uratic  deposits  in  gout  and  arthritis 
deformans,  and  the  alteration  of  the  cells  lining  the  vessels  in 
arterio-sclerosis,  and  it  does  seem  reasonable  to  believe  that 
long  continued  irritation  of  cells  by  some  of  the  purin  bases  can 
excite  them  to  the  morbid  action  which  we  call  cancer.  Cer- 
tainly all  the  treatment  which  I  have  given,  dietary  and  medi- 
cinal, with  success,  is  along  the  lines  of  modifying  or  removing 
elements   which   tend   to   the  production   of   uratic   features. 

There  are  yet  other  considerations  concerning  the  relation 
of  diet  to  cancer,  which  are  worthy  of  attention.  We  have 
mentioned  some  principal  agents  which  seem  unquestionably 
to  have  an  influence  in  the  production  and  continuance,  and 
even  recurrence  of  cancer,  namely  proteids,  coffee  and  tea,  and 
alcoholics.  But  millions  of  human  beings  partake  of  these 
with  apparent  immunity,  while  in  the  relatively  few  they  appear 
to  have  cancer-genetic  powers.  This  need  not  surprise  or 
puzzle  us  any  more  than  do  the  many  other  problems  in  medi- 
cine which  we  are  seeking  to  solve:  for  we  know  that  the  system 
often  reaches  a  point  where  certain  things,  once  well  borne,  are 
no  longer  tolerated.  We  know,  for  instance,  that  Port  and 
Madeira  wine  can  certainly  cause  gout,  but  with  many  indivi- 
duals they  may  be  indulged  in  freely  for  some  time  before  this 
result  follows.  We  must  remember  that  it  is  not  the  alcoholic 
content  of  this  that  does  the  mischief,  as  much  as  it  is  the  acids 
and  some  other  of  the  28  elements  of  which  they  are  composed. 
Likewise  that  tobacco  may  even  be  abused  for  a  long  time, 


RELATION  OF  DIET  TO  CANCER  219 

without  apparent  ill  effects,  when  suddenly  there  is  a  revulsion 
of  the  system,  and  the  slightest  use  of  tobacco  will  be  intoler- 
able. Also  that  many  edible  substances  which  have  long  been 
well  borne,  will  at  a  certain  time  act  unfavorably  and  excite  erup- 
tions, urticaria,  acne,  eczema,  etc.,  and  we  are  only  beginning  to 
understand  some  of  the  strange  conditions  associated  with 
anaphylaxis. 

Psoriasis  also  furnishes  an  illustration  which  may  be  of 
service  in  understanding  the  relation  of  diet  to  cancer.  For 
psoriasis  is  characterized  by  a  disordered  epithelial  growth, 
which  shows  both  on  the  surface  and  manifests  itself  by  epithel- 
ial prolongations  into  the  corium,  which  are  quite  comparable 
to  the  ingrowing  cellular  masses  of  some  forms  of  cancer. 
Moreover,  cancer  is  not  very  rare  in  psoriatic  patients.  In 
this  eruption  it  has  been  very  clearly  demonstrated,  clinically 
and  experimentally,  that  error  in  nitrogenous  metabolism  is 
commonly  at  the  bottom  of  the  disease,  and  I  have  repeatedly 
seen  the  eruption  promptly  and  entirely  disappear  simply 
under  an  absolute  vegetarian  diet  alone,  correctly  regulated,  ex- 
cluding also  coffee  and  alcohol,  without  the  use  of  any  medical 
treatment  whatever,  internal  or  external,  and  then  return  when 
these  dietary  measures  were  neglected:  but,  of  course,  this 
result  cannot  always  be  obtained,  and  sometimes  the  eruption 
will  resist  during  what  is  claimed  to  be  a  vegetarian  diet.  There 
must,  therefore,  be  some  systemic  disturbance  which  causes 
nutritive  material,  at  some  particular  time,  thus  to  derange 
cell  action  in  the  eruptions  mentioned,  and  the  same  is  true  in 
regard  to  the  production  of  cancer. 

Some  years  ago  Braithwaite1  called  attention  to  the  occur- 
rence of  cancer  among  certain  people  who  were  vegetarians,  and 
attributed  it  to  the  great  amount  of  salt  which  they  consumed. 
While  the  objection  that  salt,  which  is  a  prominent  constituent 
of  the  blood,  can  be  a  cause  of  cancer  has  been  ridiculed,  it  is 
quite  possible  that  a  great  excess  of  sodium  chloride  may 
disturb  the  salt  equilibrium  in  the  blood,  by  replacing  the 

1  Braithwaite,  Lancet  1902,  Vol.  1,  p.  400. 


220  CANCER 

potassium  which  is  such  a  feature  in  cell  life,  as  shown  by 
Forbes  Ross,  and  also  by  hindering  the  excretion  of  uric  acid, 
as  Haig  has  pointed  out.  This  matter  of  salt  in  relation  to 
cancer  has  recently  been  agitated  strongly  by  Robinson1  who 
gives  cases  illustrating  the  advantage  of  limiting  its  intake.  We 
do  know  that  the  restriction  of  salt  in  the  diet  is  an  important 
matter  in  connection  with  certain  kidney  and  other  conditions 
of  disease. 

When  we  inquire  into  the  cause  of  the  systemic  disturbance 
which  tends  to  such  faulty  metabolism  that  the  nutrition  of 
cellular  structures  is  deranged,  even  to  the  degree  of  taking  on 
malignant  action,  we  find  many  elements,  more  or  less  connected 
with  what  is  known  as  modern  civilization,  which  have  been 
considered  in  another  chapter  but  may  be  briefly  alluded  to 
here.  Williams  has  shown  pretty  clearly  that  wealth,  with  its 
tendency  to  luxury  and  idleness,  greatly  increased  the  proclivity 
to  cancer.  Not  only  is  this  observed  in  different  countries, 
but  in  certain  cities  the  difference  is  very  striking  between  the 
cancer  mortality  in  sections  which  are  occupied  by  the  rich 
and  well-to-do,  and  those  in  which  the  poorer  classes  are 
herded.  Also  in  England  it  was  found  that  in  one  decennium 
cancer  nortality  was  more  than  twice  as  great  among  the  well- 
to-do  men,  having  no  specific  occupation,  as  it  was  among 
occupied  males  in  general,  the  ratio  being  96  to  44. 

Change  in  the  mode  of  life,  and  sudden  changes  of  environ- 
ment and  urbanization  have  also  been  found  to  have  a  great 
effect  in  the  production  of  cancer.  As  Bell  remarks:  "Cancer 
is  essentially  a  disease  supervening  upon  a  persistent  neglect  of 
hygienic  laws." 

Finally,  nervous  conditions  unquestionably  can  and  very 
often  do  exert  a  profound  influence  on  the  secretions  of  the 
various  organs  of  the  body,  and  can  so  disturb  digestion, 
metabolism,  and  nutrition  that  the  most  varied  results  may 
follow.  Witness  the  now  well  attested  fact  that  sudden  fright 
or  grief  can  cause  a  complete  greyness  of  the  hair,  even  in  a 

1  Robinson,  The  Medical  Record,  Aug.  24,  1920. 


RELATION  OF  DIET  TO  CANCER  221 

very  brief  time.  So  that  nerve  strain,  more  or  less  incident 
to  modern  life,  must  be  accredited  with  a  certain  share  in  the 
production  of  cancer,  as  many  have  observed. 

It  is  seen,  therefore,  that  there  are  many  contributing  factors 
in  the  causation  of  cancer.  But  the  fact  remains  that  the  proper 
diet  must  lie  at  the  bottom  of  all  effective  medical  treatment. 
We  also  see  that  it  is  not  meat  eating  alone  which  induces  the 
neo-plastic  growth,  but  that  disordered  metabolism  is  the 
fundamental  cause,  and  this  is  influenced  by  diet  to  such  a 
degree  that  without  this  being  properly  controlled,  as  will  be 
shown  in  the  chapter  on  treatment,  simple  medical  or  surgical 
measures  can  never  hope  to  check  its  ravages. 


CHAPTER  XIV 

MORTALITY  FROM  CANCER :  ANALYSIS  OF  SURGICAL 

STATISTICS 

The  chapter  on  the  "Frequency  and  Geographical  Distribu- 
tion of  Cancer"  was  based  largely  on  its  mortality,  but  this 
may  with  advantage  be  briefly  alluded  to  in  connection  with  the 
resulst  of  the  surgical  treatment  of  the  disease. 

The  total  deaths  from  cancer  in  the  United  States  each  year 
is  estimated  at  about  80,000,  judging  from  the  actual  reports 
from  the  States  which  are  included  in  the  registration  area,  as 
shown  by  the  United  States  Mortality  Reports.  In  the  registra- 
tion area,  covering  an  estimated  77.8  per  cent  of  the  whole 
population,  there  were  65,340  deaths  from  cancer  and  other 
malignant  tumors,  during  1918,  and  68,551  in  1919. 

Interesting  confirmation  of  the  actual  and  certain  increase 
in  the  mortality  from  cancer  in  the  United  States  is  furnished 
by  a  study  of  the  table  given  on  page  15  of  the  Special  Report 
of  the  Mortality  from  Cancer  in  the  Registration  Area  of  the 
United  States,  for  1914.  In  1900,  the  estimated  population 
of  the  registration  area  was  30,765,618,  and  in  1914,  the  larger 
area  included  a  population  of  65,989,295,  or  had  a  little  over 
doubled;  and,  whereas  in  1910  the  cancer  deaths  were  19.381, 
in  1914  they  were  52.420,  that  is,  the  cancer  deaths  had  nearly 
tripled  in  these  14  years,  while  the  population  had  only  a  little 
more  than  doubled. 

In  New  York  City,  by  the  Reports  of  the  Board  of  Health, 
there  were  in  1919,  5,124  such  deaths,  (2,250  males,  2,874 
females),  with  an  increase  of  more  than  4.6  per  cent  over  the 
preceding  year.  This  is  remarkable  and  unexplainable,  for 
in  1 91 8,  the  increase  was  less  than  one  per  cent  over  those  in 


MORTALITY  FROM  CANCER  223 

191 7.  This  total  number  of  deaths,  5,124,  divided  by  365 
days,  makes  an  average  of  over  14  deaths  daily  from  malignant 
neo-plasms,  against  13.39  persons  dying  daily  in  1918.  The 
lowest  number  recorded  in  any  one  week  in  1918,  was  81,  or 
11.52  persons  daily,  and  the  highest  was  the  surprising  number 
of  132,  or  18.83  each  day,  in  the  week  ending  December  20th: 
the  next  highest  week,  ending  December  6th,  gave  119  deaths 
from  cancer,  or  an  average  of  17  per  day.  During  the  first 
6  months  of  1920,  there  were  2,670  deaths  from  this  cause,  or 
14.59  persons  daily.  Surely  this  increase  in  the  reported 
mortality  is  not  one  due  as  is  commonly  claimed,  to  :  1.  In- 
creased longevity  in  general,  leading  to  the  existence  of  more 
people  of  the  cancerous  age;  or  2.  Improved  diagnosis;  or  3. 
More  careful  death  certification:  these  often  alleged  causes  of 
the  steadily  rising  mortality  could  hardly  be  operative  in  New 
York  City  in  6  months  or  a  year  and  during  the  last  six 
months  of  the  year,  as  we  have  already  mentioned,  the  recorded 
cancer  deaths  were  actually  2691,  an  excess  of  22  over  those 
from  tuberculosis. 

The  mortality  from  cancer  varies  greatly  in  different  States 
of  the  Union,  but  in  almost  every  instance  there  has  been  an 
increase  worthy  of  note.  We  will  give  that  per  100,000  popula- 
tion, for  19 1 8  as  compared  with  that  in  191 1,  which  is  shown  in 
the  last  Government  Report.  Maine  107.5  against  98.6:  New 
Hampshire  107.3,  96.8:  Massachusetts  107.2,  94.4:  California 
106.0,  82.6:  Vermont  shows  a  decrease,  99.7,  101.0  (but  in  1916 
it  was  1 14.9  per  100,000) :  New  York  State  93.2  against  86.3  per 
100,000  population.  The  lowest  rates  in  1918,  are  shown  for 
South  Carolina  34.4:  North  Carolina  43.5:  Tennessee  44: 
Louisiana  46.4:  and  Utah  50.5.  In  all  the  states  in  which  it  is 
given,  the  death  rate  is  lower  among  the  colored  than  among  the 
whites,  except  Kentucky,  where  it  is  a  trifle  higher.  The  lowest 
mortality  among  the  colored  people  was  in  South  Carolina, 
where  it  was  27.4  to  the  100,000  against  42.3  among  the  whites. 

The  cities  also  vary  greatly  in  the  number  of  reported  deaths 
from  cancer,  and  as  a  rule  show  a  higher  percentage  than  that 


224 


CANCER 


of  the  state  in  general.  This  is  owing  in  part  to  the  number  of 
patients  coming  for  treatment  and  also  to  the  more  complex  life 
of  the  cities,  with  the  greater  temptations,  leading  to  the  dis- 
turbances of  metabolism  causing  cancer.  Thus,  the  average  of 
20  large  cities  gives  a  rise  in  the  death  rate  of  cancer  from  48.6  in 
1S81  to  1S85,  to  89.3  per  100,000  living  in  1913. 

The  following  table  gives  the  average  cancer  mortality  from 
1906  to  1910  per  100,000  in  certain  American  cities: 


San  Francisco 

Boston 

Providence 

Los  Angeles 

Cincinnati 

Hartford 

New  Haven 

Dayton 

Rochester 

Springfield,  Mass 

District  of  Columbia. . .  . 

Baltimore 

Omaha 

Buffalo 

New  Orleans 

Philadelphia 

Hoboken 

Columbus 

Manhattan  and  Bronx.  . 

St.  Louis 

Denver 


102 

99 

96 

94 
93 
9i 


Newark 76.9 

Chicago 76.5 

Greater  New  York 74. 1 

Richmond 73-9 

Kansas  City,  Mo 71 . 1 

St.  Paul 71. 1 

Indianapolis 70.4 

Borough  of  Brooklyn.. .  .  68.9 

Milwaukee 68.4 

Nashville 68 .  o 

Pittsburgh 66.4 

Minneapolis 65.3 

Detroit 64.5 

Cleveland 62.9 

Louisville 61 . 1 

Jersey  City 60. 5 

Charleston 53 . 6 

Seattle 50.  2 

Augusta,  Ga 49 . 1 

Memphis 48 . 7 

Savannah 47.1 


It  is  readily  understood  that  many  factors  enter  into  the 
study  and  proper  understanding  of  the  statistics  of  the  mortality 
of  cancer,  such  as  age,  sex,  location  of  the  lesion,  race,  etc.,  and 
it  is  quite  impossible  in  the  present  writing,  or  from  any  data 
accessible,  to  make  any  such  analysis  in  full,  but  a  few  points 
may  be  mentioned. 

Thus,  in  regard  to  age,  the  states  which  represented  the  great- 
est number  of  deaths  from  cancer — Maine  with  107.5;  New 
Hampshire,  107.3;  Vermont,  99.7  (114. 9  in  1916) — per  100,000, 
show  that  the  proportion  of  individuals  45  years  of  age  or  older 


MORTALITY  FROM  CANCER  225 

was  over  27  per  cent,  compared  with  17.7  per  cent  for  Kentucky 
and  16.2  per  cent  for  Montana,  which  latter  gave  almost  the 
lowest  mortality  for  cancer. 

The  same  is  somewhat  true  in  regard  to  sex,  although  suffi- 
cient data  are  not  at  hand  to  show  the  relative  number  of  males 
and  females  in  different  states.  Of  the  total  deaths  from  cancer 
in  the  United  States  in  1918,  38,619,  or  59.1  per  cent  were 
females,  and  26.721,  or  40.9  per  cent  males,  although  the  male 
population  in  the  registration  area  exceeds  the  female. 

We  know,  of  course,  that  the  great  preponderance  of 
deaths  from  cancer  in  females  is  due  to  the  disease  affecting 
the  breast  and  uterus,  and  where  females  preponderate  the 
total  cancer  mortality  would  be  higher.  The  general  mor- 
tality for  cancer  has  always  been  higher  in  females,  but  that 
of  males  is  steadily  gaining,  owing  it  is  thought  to  the  steady 
increase  of  deaths  from  cancer  of  the  stomach,  liver,  and 
intestines  in  males. 

The  location  of  the  lesion  has  also  a  bearing  upon  the  under- 
standing of  statistics.  Thus,  in  Norway,  for  some  unexplained 
reason,  cancer  of  the  stomach  seems  to  be  extremely  common. 
With  a  death  rate  from  cancer  in  general,  in  1912,  of  104.8  per 
100,000  inhabitants  (risen  from  50.6  in  1886),  there  is  reported 
by  Dr.  Soergaard  *  a  mortality  of  60  per  cent  of  all  to  be  from 
cancer  of  the  stomach,  while  those  from  the  breast  and  uterus 
are  very  few. 

In  the  United  States,  in  191 8,  cancer  of  the  stomach  and  liver 
caused  the  death  of  23,845  persons,  of  these  12,208  were  males 
and  1 1,637  females.  The  total  cancer  deaths  were  25,780  males, 
of  which  almost  one-half  were  from  cancer  of  the  stomach  and 
liver,  and  36,379  females,  of  which  less  than  one-third  were 
from  this  cause.  Cancer  of  the  uterus  caused  8,043  deaths,  and 
that  of  the  breast,  6,040,  a  total  of  15,043,  or  41  per  cent  of  all 
the  cancer  deaths  in  females,  and  23  per  cent  of  all  deaths  from 
cancer  in  both  sexes. 

1  Soergaard,  "Die  Krebsform.  Norweg.  Zeitschr.  f.  Krebsforcsh."  1913 
(Hoffman,  p.  633). 

15 


226  CANCER 

Deaths  in  the  United  States  Registration  Area,  1918 


Age  of 
decedent 


Carcinoma 


Male       Female 


Sarcoma 


Hyper-nephroma 


Male       Female 


Male       Female 


All  ages. 


24,715 


36,780 


1,923 


i,795 


83 


44 


Under  1  year. 

1  year 

2  years 

3  years 

4  years 


9 

6 

12 

12 


22 

32 
26 
23 
19 


13 
17 


20 
22 


Under  5  years 

o    9  years 

0  14  years 

o  19  years 

24  years 

o  29  years 

o  34  years 

0  39  years 

0  44  years 

o  49  years 

o  54  years 

o  59  years 

o  64  years 

o  69  years 

o  74  years 

o  79  years 

o  84  years 

o  89  years 

o  94  years 

o  99  years 

100  years  and  over. 
Unknown  age 


47 
27 

23 

34 
81 

155 

3°7 

611 

1,069 

1,711 

2,602 

3,201 

3,714 

3,759 

3,278 

2,246 

1,106 

481 

102 

27 

6 

38 


61 

28 

17 

43 

146 

386 

856 

1,626 

2,719 

3,738 

4,246 

4,695 

4,694 

4,566 

3,856 

2,686 

i,540 

613 

178 

27 

7 

52 


122 

44 

49 

75 

89 

in 

104 

126 

130 

131 
172 
210 
163 
141 
126 
70 
38 

19 

2 


90 

4i 

35 

65 

58 

75 

79 

96 

125 

167 

166 

156 

172 

154 

126 

109 

5i 

23 

6 


2 
6 

15 
6 

14 

13 
12 

5 


Race  also  seems  to  have  something  to  do  with  the  mortality 
from  cancer,  although  as  statistics  develop,  it  is  seen  that  habits 
of  life  in  natives  modify  the  death  rate,  according  as  these  later 
approach  to  that  of  foreigners  with  whom  they  come  in  contact. 

Thus,  in  slavery  times  the  negroes  were  said  to  have  almost 
no  cancer,  when  they  lived  simple  lives  and  worked  hard.     But 


MORTALITY  FROMJZANCER  227 

since  their  freedom,  and  as  they  mingled  with  others,  serving 
in  hotels,  etc.,  the  death  rate  has  steadily  increased. 

In  studying  the  latest  Mortality  Tables  of  19 18,  it  is  rather 
surprising  to  find  that  in  New  York  City,  with  a  total  of  4,985 
deaths  from  cancer,  there  were  only  96  in  colored  persons:  of 
course  no  judgment  can  be  formed  from  this  without  knowing 
the  relative  number  of  the  latter  in  the  city,  which  cannot  be 
stated;  the  percentage  of  total  deaths  from  cancer,  among  the 
colored  is  always  very  much  lower  than  among  the  whites,  in 
every  state  but  one  in  which  they  are  recorded. 

The  Polynesians  and  Melanesians  seem  to  be  peculiarly 
exempt  from  cancer.  Sir  William  McGregor1,  although  he  had 
operated  several  times  for  cancer  in  whites  in  the  Fiji  Islands, 
never  remembers  operating  on  a  Polynesian  or  Melanesian, 
who  are  vegetarians.  He  never  saw  a  case  of  cancer  in  British 
Guiana  in  g}i  years,  and  then  saw  an  encephaloid  cancer  of  the 
tibia  in  a  Papuan,  who  for  7  or  8  years  had  lived  practically  a 
European  life,  eating  canned  Australian  meat  daily. 

As  regards  Africa,  Williams  quotes  Dr.  Madden2  of  Cairo, 
who  says:  "The  consensus  of  opinion  among  medical  men  in 
Egypt  is,  that  cancer  is  never  found,  either  in  male  or  female, 
among  the  black  races  of  that  country.  These  include  the 
Berberines  and  the  Sudanese,  who  are  all  Musslemans,  and  live 
almost  entirely  on  vegetable  diet."  Of  19,529  deaths  among 
natives  of  Cairo  in  189 1,  only  19  were  due  to  cancer  (9  males  and 
10  females)  or  1  in  1,028,  while  in  England  during  the  same  year 
the  proportion  of  cancer  deaths  to  total  deaths  was  1  to  29. 
In  the  Islands  of  Lagos,  on  the  west  coast  of  Africa,  Dr.  John- 
son3 in  14  years'  practice  there  saw  five  cases  of  cancer  in  natives 
all  of  whom  lived  as  Europeans.  Renner4  reports  interestingly 
in  regard  to  cancer  among  the  descendants  of  liberated  Africans 
or  Creoles,  in  Sierre  Leone,  Africa.     During  30  years,  from  1870 

1  McGregor,  Brit.  Med.  Jonrn.,  1900,  ii,  p.  982. 

2  MADDEN-quoted  by  Williams,  p.  43,  Brit.  Med.  Journ.,  1902,  Vol.  2,  p. 
730. 

3  Johnson,  Brit.  Med.  Journ.,  1900,  ii,  p.  982. 

4  Renner,  Brit.  Med.  Journ.,  1910,  ii,  p.  587;  also  1911,  i,  p.  no. 


228  CANCER 

to  1900,  there  were  but  30  cases  recorded  of  malignant  disease 
among  22,453  admitted  to  the  Colonial  Hospital:  in  the  next 
10  years  there  were  26  among  a  total  of  10,163,  a  slow  but 
steady  gain  in  cancer  incidence,  with  the  advancing  influence  of 
the  white  man.  More  of  tins  evidence  will  be  found  in  other 
chapters,  and  we  need  not  dwell  on  it  longer  here. 

Realizing,  then,  that  the  mortality  of  cancer  is#  materially 
and  steadily  rising,  in  spite  of  most  diligent  research  by  innum- 
erable honest  and  capable  scientists,  with  the  expenditure  of 
vast  sums  of  money  and  countless  animal  lives,  and  in  spite 
of  the  work  of  ardent,  earnest,  and  capable  surgeons,  to  whom 
all  honor  is  due,  but  who  have  failed  to  stay  the  terrible  progress 
of  the  disease,  let  us  briefly  study  some  of  the  reported  statistics 
in  regard  to  operative  interference  in  cancer. 

It  may  be  first  stated  that  this  is  a  most  difficult  task,  so 
different  are  the  reports  from  different  surgeons.  There  are 
many  elements  which  affect  the  statistics  relating  to  the  surgery 
of  cancer,  which  we  will  briefly  consider  in  turn. 

First,  as  to  the  stage  of  the  disease  at  which  the  operation  was 
performed.  We  have  tried  to  show  that  the  lesion  which  we 
call  real  cancer  is  but  the  result  of  a  deranged  blood  state, 
probably  of  long  existence,  and  that  the  whole  trouble  is  not  a 
purely  local  process,  a  something  simply  to  be  removed 
surgically  in  order  to  have  the  patient  get  well  and  remain  well. 
For  one  sees  plenty  of  cases  where  there  were  recurrences 
shortly  after  removal,  even  after  the  very  earliest  operations 
possible,  especially  on  the  breast  and  uterus.  But  the  claims 
put  forth  that  favorable  results  are  conditional  on  very  early 
operations  are  so  strenuous  and  persistent  that  we  must  perhaps 
believe  that  a  measure  of  the  favorable  results  claimed  can  be 
thus  accounted  for.  Though,  as  already  mentioned,  the  ex- 
cision of  lesions  which  were  pronounced  microscopically  not  to 
be  cancerous  have  been  followed  by  unmistakable  cancer.  We 
know,  of  course,  that  very  late  in  the  disease,  and  in  recurrences, 
operations  are  out  of  the  question,  and  commonly  harmful. 

It  is  a  little  curious,  however,  that  most  of  the  pictures 


SURGICAL  STATISTICS  OF  CANCER  229 

shown,  statistics  presented,  and  arguments  advanced  by  these 
advocates  of  early  operations,  relate  to  cutaneous  epithelioma, 
mainly  about  the  face,  which  cause  a  very  small  mortality, 
which  would  be  very  much  less  if  the  disease  were  properly  cared 
for  at  the  beginning,  for  their  early  recognition  is  relatively  easy. 
Moreover,  those  who  see  much  of  cutaneous  epithelioma  know 
that  if  rightly  handled  early,  it  is  generally  a  comparatively 
mild  affair  and  relatively  easily  cured  without  a  surgical 
operation,  as  by  x-ray,  radium,  certain  pastes,  etc.  And,  as 
already  mentioned,  it  is  excluded  in  our  present  study  of  cancer 
as  a  disease,  for  it  is  really  a  local  epithelial  degeneration  from 
external  causes.  But  mortality  statistics  are  greatly  influenced 
by  the  class  of  cases  which  an  operator  takes,  and  so  if  epithe- 
lioma of  the  skin  is  included  the  ratio  of  cures  will  be  higher. 
Selected  cases  also  always  give  more  favorable  statistics. 

Second,  the  knowledge  and  skill  of  the  operator,  and  the 
perfection  of  technique  undoubtedly  influence  surgical  statistics. 
The  ordinary  practitioner  or  surgeon  cannot  hope  for  as  favor- 
able results  in  many  operations  for  cancer  as  can  those  who  are 
past  masters  in  this  line,  and  these  latter  are  the  ones  who 
furnish  the  most  favorable  statistics. 

Third,  the  class  of  cases  operated  on  affect  surgical  statistics 
very  greatly.  While  cutaneous  epithelioma  of  the  face,  and 
even  of  the  lip,  when  well  removed,  may  yield  favorable  statis- 
tics, cancer  of  the  breast,  uterus,  stomach,  intestines,  gall 
bladder,  etc.,  still  yield  even  increasingly  unfavorable  statistics, 
as  will  be  presently  seen. 

Fourth,  the  duration  of  observation  after  operation  affects 
very  seriously  the  validity  of  statistics.  Not  long  ago  three 
years'  freedom  from  the  disease  was  considered  the  time  to 
regard  a  cancer  as  permanently  cured.  But  this  time  has 
been  lengthened  more  and  more,  by  the  observation  of  many 
cases  where  the  disease  has  recurred  even  long  afterwards, 
and  reliable  observers  are  now  very  chary  in  expressing  an 
opinion  as  to  the  final  cure  of  cancer;  and  some  surgeons,  as 
Deaver,  already  quoted,  say:  "We  still  do  nothing  to  cure  it." 


230  CANCER 

Finally,  the  optimism  of  the  reporter  seems  often  to  have 
something  to  do  with  the  reliability  of  surgical  statistics. 
This  need  hardly  be  discussed.  The  older  and  more  experi- 
enced the  surgeon,  the  less  confident  he  is  of  having  actually 
cured  cancer  with  the  knife.  At  a  discussion  on  cancer  in 
the  New  York  Academy  of  Medicine  some  years  ago,  Dr. 
Robert  F.  Weir  of  New  York,  said  that  the  late  Dr.  Agnew, 
a  celebrated  surgeon  of  Philadelphia,  had  remarked  just  before 
his  death  that  he  doubted  if  he  had  ever  been  justified  in  an 
operation  upon  cancer,  and  he,  Dr.  Weir,  stated  that  he  could 
almost  say  the  same.  At  a  recent  meeting  of  a  County  Medical 
Association  in  a  neighboring  city,  a  very  prominent  surgeon, 
60  years  old,  operating  over  a  wide  district,  said:  "Mr.  Presi- 
dent and  Gentlemen:  I  have  done  with  operations  on  cancer, 
and  hope  that  no  one  will  ever  ask  me  again  to  operate  on 
that  disease.  I  do  not  know  if  I  have  ever  done  enough  good 
to  warrant  the  operation."  A  very  prominent  anesthetist, 
who  has  had  a  very  great  deal  to  do  with  operations  on  cancer, 
remarked  to  me  recently  that  he  was  struck  with  the  unfortu- 
nate results  of  operations  on  the  disease.  Although  there  are 
still  occasional  records  of  cancer  operations  reported  as  success- 
ful, there  is  seldom  mention  of  observation  long  enough  to 
determine  if  the  disease  was  eradicated. 

Turning  now  to  the  actual  statistics  of  operative  surgery  on 
cancer,  we  will  find  that  the  percentage  of  reported  cures 
varies  greatly  in  accordance  with  the  points  just  stated.  It  is  un- 
derstood, of  course,  that  no  accurate  statements  can  be  made 
in  regard  to  the  actual  mortality  from  cancer  in  any  location, 
partly  owing  to  the  paucity  of  reliable  figures,  and  partly 
because  the  stages  and  extent  of  the  disease  differ  so  greatly 
in  different  cases,  and  the  final  results  vary  with  the  previous 
duration  of  the  disease  and  the  period  of  observation  after  the 
operation,  which  is  seldom  stated. 

Cancer  or  epithelioma  of  the  skin  presents  the  best  operative 
statistics  of  any  region,  and  the  claim  is  made  that  all  cases  are 
curable  if  operated  on  early  enough  and  rightly.     While  this  is 


SURGICAL  STATISTICS  OF  CANCER  231 

not  wholly  true,  it  is  certain  that  if  all  lesions  which  one  chooses 
to  call  "pre-cancerous"  are  thoroughly  extirpated  very  early, 
and  all  of  them  included  as  cancer  in  statistics,  the  percentage 
of  cures  can  be  reported  as  very  high.  So  that  it  may  be  said 
that,  taking  all  statistics  together,  including  very  small  as  well 
as  large  lesions,  the  favorable  results,  that  is  permanent  cures 
of  lesions  which  can  truly  be  called  cutaneous  epithelioma,  may, 
as  some  claim,  run  as  high  as  75  per  cent. 

But  against  this  is  set  the  fact  that  a  very  large  share  of  these 
cutaneous  epitheliomas  taken  early  and  treated  by  competent 
persons,  are  equally  amenable  to  lighter  measures,  without  the 
horrible  disfigurement  which  one  sometimes  sees  after  purely 
surgical  procedures. 

Cancer  of  the  lip,  when  treated  early,  and  skillfully,  and  radi- 
cally, including  sufficient  gland  extirpation,  also  yields  a  fairly 
satisfactory  result,  depending,  of  course,  on  the  duration  and 
stage  of  the  disease,  or  amount  of  involvement  of  tissue  and 
glands,  and  the  completeness  of  the  operation.  But  while  the 
lip  lesion  may  remain  absent,  subsequent  recurrence  in  deep 
glands  is  most  distressing  and  hopeless.  Thus,  while  some  oper- 
ators have  claimed  75  per  cent  of  cures,  Hertzler1  makes  the 
percentage  of  permanent  cure;  "not  much  over  25  per  cent," 
and  Taylor  agrees  that  this  is  approximately  correct,  if  all 
operations,  by  all  operators  were  taken  into  account.  And 
here  again,  it  may  be  remarked,  if  taken  early  and  treated 
correctly,  by  proper  local  and  constitutional  measures,  many 
of  these  cases  yield  without  the  knife,  as  will  be  seen  in  a  later 
chapter. 

When  we  come,  however,  to  cancer  within  the  mouth,  on  the 
tongue,  etc.,  it  is  quite  a  different  story,  as  mentioned  in  the 
chapter  on  prognosis,  and  the  end  results  of  surgery  are  com- 
monly unsatisfactory.  Certain  European  surgeons  have  reported 
an  operative  mortality  in  cancer  of  the  tongue  as  high  as  36  per 
cent,  while  recurrences  are  the  rule,  and  really  permanent  cures 

Hertzler,  "Treatise  on  Tumors"  quoted  by  Taylor,  "Cancer."     Phila. 
1915,  p.  193. 


232  CANCER 

the  very  great  exception.  Of  25  cases  reported  on  by  Steiner1 
there  were  .9  operative  deaths,  or  36  per  cent.  Of  the  16  that 
recovered  from  the  operation  9  died  within  the  first  year,  4  cases 
in  the  second  year,  and  the  result  in  3  cases  was  unknown. 
Of  Steiner 's  25  cases  12,  or  nearly  50  per  cent,  were  operated  on 
within  the  first  3  months  of  the  apparent  onset  of  the  disease. 
Of  51  cases  reported  by  Erlich2  there  were  13  operative  deaths, 
or  over  25  per  cent,  and  but  five  cases  were  free  of  recurrence  at 
the  end  of  5  years. 

As  before  stated,  it  is  extremely  difficult  to  give  any  true  and 
accurate  estimate  of  the  real  end  results  from  operative  surgery, 
as  ordinarily  performed,  in  cancer  affecting  various  regions. 
The  obvious  reason  is  that  most  of  our  statistics  are  from  those 
who  are  especially  occupied  with  the  disease,  and  under  most 
favorable  hospital  facilities;  and  also  certain  statistics  may  be 
from  selected  cases.  Moreover,  operators  are  naturally  in- 
clined to  report  mainly  satisfactory  results,  and  that  also  too 
soon  after  operation  to  afford  a  just  and  fair  statement  of  end 
results,  while  the  unfavorable  aspects  are  seldom  fully  presented. 
Aside  then  from  superficial  epitheliomata,  about  the  only  loca- 
tion in  which  there  is  even  a  fair  chance  for  the  patient  under 
the  knife,  should  be  the  relatively  accessible  regions  of  the  breast, 
uterus,  intestines,  and  rectum,  and  for  these  large  statistics  are 
on  record;  but  again  these  are  unsatisfactory,  as  they  vary  so 
greatly. 

In  cancer  of  the  breast  the  statistics  are  very  provoking.  In- 
dividual operators  have  claimed  as  high  as  50  and  even  75  per 
cent  of  cases  (Rodman).3  John  B.  Murphy,4  on  the  other  hand, 
on  the  basis  of  end  results,  states  that  the  plump  woman  invari- 
ably succumbs,  and  that  Paget's  disease  ends  fatally  in  90  per 
cent  of  the  cases. 

Hilderbrand  mentions  606  operations,  in  which  the  percent- 

1  Steiner,  Deutch.  Zeitschr.  f.  Chir.  Vol.  98.    Quoted  by  Taylor,  p.  182. 

2  Erlich,  Arch.  f.  Klin.  Chir.  Vol.  lxxviii.     Quoted  by  Taylor,  p.  182. 
3 Rodman.     Jour.  Amer.  Med.  Asso.,  Feb.  27,  1915. 

*  Murphy,  Clinics,  Aug.  12,  Aug.  19,  1913,  Dec.  12,  Sept.  14,  June  14. 


RELATION  OF  DIET  TO  CANCER  2 1 7 

tobacco  should  not  be  overlooked  in  regard  to  cancerous  mouth 
lesions.  But  of  the  millions  who  use  tobacco  only  very  few  are 
affected  with  cancer,  and  as  far  as  we  can  see,  only  those  pre- 
disposed thereto  by  some  metabolic  disturbance,  as  has  been 
previously  considered.  It  has  been  already  mentioned  that  I 
have  found  the  saliva  to  be  acid  almost  invariably  in  cancer 
patients,  even  in  those  with  early  disease,  and  I  think  I  have 
never  found  it  otherwise,  unless  altered  by  treatment,  in  those 
with  malignant  lesions  within  the  mouth.  With  this  there  is  a 
faulty  preparation  of  carbonaceous  and  fatty  foods. 

Mayo1  says:  "In  civilized  man  one-third  of  all  cancers  are 
seated  in  the  stomach.  This  is  not  known  to  be  the  case  in 
uncivilized  man,  or  in  animals.  There  should  therefore  be 
something — some  one  cause — which  causes  the  preponderance. 
The  acid  secretion  may  favor  its  development,  for  when  we 
come  to  the  colon,  also  with  an  acid  secretion,  we  again  meet 
with  cancer,  and  we  seldom  see  it  in  the  alkaline,  small  intestine. 
Gastric  ulcer,  which  may  be  pre-cancerous,  is  connected  with 
hyper-acidity. 

In  Scandanavia  cancer  of  the  stomach  is  remarkably  frequent, 
according  to  Soegaard;2  thus  of  1,235  cancer  cases  in  Norway, 
73.9  per  cent  were  in  that  location.  In  a  former  chapter  we 
saw  that  cancer  in  general  was  connected  with  a  lowered 
alkalescence  of  the  blood,  and  all  our  studies  show  hyper- 
acidity to  be  related  to  cancer  genesis.  Nitrogenous  acidity, 
or  uric  acid  (purim  bases,  xanthin,  etc.)  undoubtedly  plays  a 
great  part  in  inducing  malignant  action  in  tissues,  as  Haig3  has 
so  long  contended,  even  in  regard  to  cancer;  and  the  almost 
invariable  occurrence  of  rheumatic  and  neuritic  symptoms  in 
cancer  patients,  even  in  regions  far  distant  from  definite  lesions, 
shows  this  strongly.  Such  pains,  as  also  the  pains  in  active 
cancerous  lesions  are  continually  found  to  be  controlled  by 
efficient  repeated  administration  doses  of  aspirin,  which  also 
seems  to  help  the  cancer  itself. 

1  Mayo,  "Annals  of  Surgery."     1914,  p.  587. 

2  Soegaard,  "Zeitschr.  fur  Krebsforsch."     1913,  p.  89. 

3  Haig,  "Uric  Acid  in  the  Causation  of  Disease."     7th  edition,  1908,  p.  420. 


218  CANCER 

Although,  as  far  as  I  know,  there  are  no  scientilic  observations 
to  prove  it.  still  I  cannot  help  feeling,  from  a  long  clinical  study 
of  cancer  as  a  disease,  that  xanthin  or  some  of  the  purin  bases, 
has  to  do  with  the  erroneous  and  erratic  action  of  the  cells 
which  result  in  cancer.  We  have  seen  in  a  previous  chapter 
how  the  cancer  cells  change  from  the  form  of  normal  cells, 
and  in  the  chapter  on  the  bio-chemistry  of  cancer,  that  there 
were  changes  in  their  chemical  constituents,  especially  in  regard 
to  the  nuclei  which  supply  the  endogenous  purin,  and  we  shall 
see  later  how  cutting  off  the  supply  of  exogenous  purin  checks 
the  disease.  We  know  of  uratic  deposits  in  gout  and  arthritis 
deformans,  and  the  alteration  of  the  cells  lining  the  vessels  in 
arterio-sclerosis,  and  it  does  seem  reasonable  to  believe  that 
long  continued  irritation  of  cells  by  some  of  the  purin  bases  can 
excite  them  to  the  morbid  action  which  we  call  cancer.  Cer- 
tainly all  the  treatment  which  I  have  given,  dietary  and  medi- 
cinal, with  success,  is  along  the  lines  of  modifying  or  removing 
elements   which   tend   to   the  production   of   uratic   features. 

There  are  yet  other  considerations  concerning  the  relation 
of  diet  to  cancer,  which  are  worthy  of  attention.  We  have 
mentioned  some  principal  agents  which  seem  unquestionably 
to  have  an  influence  in  the  production  and  continuance,  and 
even  recurrence  of  cancer,  namely  proteids,  coffee  and  tea,  and 
alcoholics.  But  millions  of  human  beings  partake  of  these 
with  apparent  immunity,  while  in  the  relatively  few  they  appear 
to  have  cancer-genetic  powers.  This  need  not  surprise  or 
puzzle  us  any  more  than  do  the  many  other  problems  in  medi- 
cine which  we  are  seeking  to  solve:  for  we  know  that  the  system 
often  reaches  a  point  where  certain  things,  once  well  borne,  are 
no  longer  tolerated.  We  know,  for  instance,  that  Port  and 
Madeira  wine  can  certainly  cause  gout,  but  with  many  indivi- 
duals they  may  be  indulged  in  freely  for  some  time  before  this 
result  follows.  We  must  remember  that  it  is  not  the  alcoholic 
content  of  this  that  does  the  mischief,  as  much  as  it  is  the  acids 
and  some  other  of  the  28  elements  of  which  they  are  composed. 
Likewise  that  tobacco  may  even  be  abused  for  a  long  time, 


RELATION  OF  DIET  TO  CANCER  219 

without  apparent  ill  effects,  when  suddenly  there  is  a  revulsion 
of  the  system,  and  the  slightest  use  of  tobacco  will  be  intoler- 
able. Also  that  many  edible  substances  which  have  long  been 
well  borne,  will  at  a  certain  time  act  unfavorably  and  excite  erup- 
tions, urticaria,  acne,  eczema,  etc.,  and  we  are  only  beginning  to 
understand  some  of  the  strange  conditions  associated  with 
anaphylaxis. 

Psoriasis  also  furnishes  an  illustration  which  may  be  of 
service  in  understanding  the  relation  of  diet  to  cancer.  For 
psoriasis  is  characterized  by  a  disordered  epithelial  growth, 
which  shows  both  on  the  surface  and  manifests  itself  by  epithel- 
ial prolongations  into  the  corium,  which  are  quite  comparable 
to  the  ingrowing  cellular  masses  of  some  forms  of  cancer. 
Moreover,  cancer  is  not  very  rare  in  psoriatic  patients.  In 
this  eruption  it  has  been  very  clearly  demonstrated,  clinically 
and  experimentally,  that  error  in  nitrogenous  metabolism  is 
commonly  at  the  bottom  of  the  disease,  and  I  have  repeatedly 
seen  the  eruption  promptly  and  entirely  disappear  simply 
under  an  absolute  vegetarian  diet  alone,  correctly  regulated,  ex- 
cluding also  coffee  and  alcohol,  without  the  use  of  any  medical 
treatment  whatever,  internal  or  external,  and  then  return  when 
these  dietary  measures  were  neglected:  but,  of  course,  this 
result  cannot  always  be  obtained,  and  sometimes  the  eruption 
will  resist  during  what  is  claimed  to  be  a  vegetarian  diet.  There 
must,  therefore,  be  some  systemic  disturbance  which  causes 
nutritive  material,  at  some  particular  time,  thus  to  derange 
cell  action  in  the  eruptions  mentioned,  and  the  same  is  true  in 
regard  to  the  production  of  cancer. 

Some  years  ago  Braithwaite1  called  attention  to  the  occur- 
rence of  cancer  among  certain  people  who  were  vegetarians,  and 
attributed  it  to  the  great  amount  of  salt  which  they  consumed. 
While  the  objection  that  salt,  which  is  a  prominent  constituent 
of  the  blood,  can  be  a  cause  of  cancer  has  been  ridiculed,  it  is 
quite  possible  that  a  great  excess  of  sodium  chloride  may 
disturb  the  salt  equilibrium  in  the  blood,  by  replacing  the 

1  Braithwaite,  Lancet  1902,  Vol.  1,  p.  400. 


220  CANCER 

potassium  which  is  such  a  feature  in  cell  life,  as  shown  by 
Forbes  Ross,  and  also  by  hindering  the  excretion  of  uric  acid, 
as  Haig  has  pointed  out.  This  matter  of  salt  in  relation  to 
cancer  has  recently  been  agitated  strongly  by  Robinson1  who 
gives  cases  illustrating  the  advantage  of  limiting  its  intake.  We 
do  know  that  the  restriction  of  salt  in  the  diet  is  an  important 
matter  in  connection  with  certain  kidney  and  other  conditions 
of  disease. 

When  we  inquire  into  the  cause  of  the  systemic  disturbance 
which  tends  to  such  faulty  metabolism  that  the  nutrition  of 
cellular  structures  is  deranged,  even  to  the  degree  of  taking  on 
malignant  action,  we  find  many  elements,  more  or  less  connected 
with  what  is  known  as  modern  civilization,  which  have  been 
considered  in  another  chapter  but  may  be  briefly  alluded  to 
here.  Williams  has  shown  pretty  clearly  that  wealth,  with  its 
tendency  to  luxury  and  idleness,  greatly  increased  the  proclivity 
to  cancer.  Not  only  is  this  observed  in  different  countries, 
but  in  certain  cities  the  difference  is  very  striking  between  the 
cancer  mortality  in  sections  which  are  occupied  by  the  rich 
and  well-to-do,  and  those  in  which  the  poorer  classes  are 
herded.  Also  in  England  it  was  found  that  in  one  decennium 
cancer  nortality  was  more  than  twice  as  great  among  the  well- 
to-do  men,  having  no  specific  occupation,  as  it  was  among 
occupied  males  in  general,  the  ratio  being  96  to  44. 

Change  in  the  mode  of  life,  and  sudden  changes  of  environ- 
ment and  urbanization  have  also  been  found  to  have  a  great 
effect  in  the  production  of  cancer.  As  Bell  remarks:  "Cancer 
is  essentially  a  disease  supervening  upon  a  persistent  neglect  of 
hygienic  laws." 

Finally,  nervous  conditions  unquestionably  can  and  very 
often  do  exert  a  profound  influence  on  the  secretions  of  the 
various  organs  of  the  body,  and  can  so  disturb  digestion, 
metabolism,  and  nutrition  that  the  most  varied  results  may 
follow.  Witness  the  now  well  attested  fact  that  sudden  fright 
or  grief  can  cause  a  complete  greyness  of  the  hair,  even  in  a 
1  Robinson,  The  Medical  Record,  Aug.  24,  1920. 


RELATION  OF  DIET  TO  CANCER  221 

very  brief  time.  So  that  nerve  strain,  more  or  less  incident 
to  modern  life,  must  be  accredited  with  a  certain  share  in  the 
production  of  cancer,  as  many  have  observed. 

It  is  seen,  therefore,  that  there  are  many  contributing  factors 
in  the  causation  of  cancer.  But  the  fact  remains  that  the  proper 
diet  must  lie  at  the  bottom  of  all  effective  medical  treatment. 
We  also  see  that  it  is  not  meat  eating  alone  which  induces  the 
neo-plastic  growth,  but  that  disordered  metabolism  is  the 
fundamental  cause,  and  this  is  influenced  by  diet  to  such  a 
degree  that  without  this  being  properly  controlled,  as  will  be 
shown  in  the  chapter  on  treatment,  simple  medical  or  surgical 
measures  can  never  hope  to  check  its  ravages. 


CHAPTER  XIV 

MORTALITY  FROM  CANCER :  ANALYSIS  OF  SURGICAL 

STATISTICS 

The  chapter  on  the  "Frequency  and  Geographical  Distribu- 
tion of  Cancer"  was  based  largely  on  its  mortality,  but  this 
may  with  advantage  be  briefly  alluded  to  in  connection  with  the 
resulst  of  the  surgical  treatment  of  the  disease. 

The  total  deaths  from  cancer  in  the  United  States  each  year 
is  estimated  at  about  80,000,  judging  from  the  actual  reports 
from  the  States  which  are  included  in  the  registration  area,  as 
shown  by  the  United  States  Mortality  Reports.  In  the  registra- 
tion area,  covering  an  estimated  77.8  per  cent  of  the  whole 
population,  there  were  65,340  deaths  from  cancer  and  other 
malignant  tumors,  during  1918,  and  68,551  in  1919. 

Interesting  confirmation  of  the  actual  and  certain  increase 
in  the  mortality  from  cancer  in  the  United  States  is  furnished 
by  a  study  of  the  table  given  on  page  15  of  the  Special  Report 
of  the  Mortality  from  Cancer  in  the  Registration  Area  of  the 
United  States,  for  1914.  In  1900,  the  estimated  population 
of  the  registration  area  was  30,765,618,  and  in  1914,  the  larger 
area  included  a  population  of  65,989,295,  or  had  a  little  over 
doubled;  and,  whereas  in  1910  the  cancer  deaths  were  19.381, 
in  1914  they  were  52.420,  that  is,  the  cancer  deaths  had  nearly 
tripled  in  these  14  years,  while  the  population  had  only  a  little 
more  than  doubled. 

In  New  York  City,  by  the  Reports  of  the  Board  of  Health, 
there  were  in  1919,  5,124  such  deaths,  (2,250  males,  2,874 
females),  with  an  increase  of  more  than  4.6  per  cent  over  the 
preceding  year.  This  is  remarkable  and  unexplainable,  for 
in  1 91 8,  the  increase  was  less  than  one  per  cent  over  those  in 


MORTALITY  FROM  CANCER  223 

1917.  This  total  number  of  deaths,  5,124,  divided  by  365 
days,  makes  an  average  of  over  14  deaths  daily  from  malignant 
neo-plasms,  against  13.39  persons  dying  daily  in  1918.  The 
lowest  number  recorded  in  any  one  week  in  1918,  was  81,  or 
11.52  persons  daily,  and  the  highest  was  the  surprising  number 
of  132,  or  18.83  eacn  day,  in  the  week  ending  December  20th: 
the  next  highest  week,  ending  December  6th,  gave  119  deaths 
from  cancer,  or  an  average  of  17  per  day.  During  the  first 
6  months  of  1920,  there  were  2,670  deaths  from  this  cause,  or 
14.59  persons  daily.  Surely  this  increase  in  the  reported 
mortality  is  not  one  due  as  is  commonly  claimed,  to  :  1.  In- 
creased longevity  in  general,  leading  to  the  existence  of  more 
people  of  the  cancerous  age;  or  2.  Improved  diagnosis;  or  3. 
More  careful  death  certification:  these  often  alleged  causes  of 
the  steadily  rising  mortality  could  hardly  be  operative  in  New 
York  City  in  6  months  or  a  year  and  during  the  last  six 
months  of  the  year,  as  we  have  already  mentioned,  the  recorded 
cancer  deaths  were  actually  2691,  an  excess  of  22  over  those 
from  tuberculosis. 

The  mortality  from  cancer  varies  greatly  in  different  States 
of  the  Union,  but  in  almost  every  instance  there  has  been  an 
increase  worthy  of  note.  We  will  give  that  per  100,000  popula- 
tion, for  191 8  as  compared  with  that  in  191 1,  which  is  shown  in 
the  last  Government  Report.  Maine  107.5  against  98.6:  New 
Hampshire  107.3,  96.8:  Massachusetts  107.2,  94.4:  California 
106.0,  82.6:  Vermont  shows  a  decrease,  99.7,  101.0  (but  in  1916 
it  was  1 14.9  per  ioo;ooo) :  New  York  State  93.2  against  86.3  per 
100,000  population.  The  lowest  rates  in  1918,  are  shown  for 
South  Carolina  34.4:  North  Carolina  43.5:  Tennessee  44: 
Louisiana  46.4:  and  Utah  50.5.  In  all  the  states  in  which  it  is 
given,  the  death  rate  is  lower  among  the  colored  than  among  the 
whites,  except  Kentucky,  where  it  is  a  trifle  higher.  The  lowest 
mortality  among  the  colored  people  was  in  South  Carolina, 
where  it  was  27.4  to  the  100,000  against  42.3  among  the  whites. 

The  cities  also  vary  greatly  in  the  number  of  reported  deaths 
from  cancer,  and  as  a  rule  show  a  higher  percentage  than  that 


224 


CANCER 


of  the  state  in  general.  This  is  owing  in  part  to  the  number  of 
patients  coming  for  treatment  and  also  to  the  more  complex  life 
of  the  cities,  with  the  greater  temptations,  leading  to  the  dis- 
turbances of  metabolism  causing  cancer.  Thus,  the  average  of 
20  large  cities  gives  a  rise  in  the  death  rate  of  cancer  from  48.6  in 
1881  to  1885,  to  89.3  per  100,000  living  in  1913. 

The  following  table  gives  the  average  cancer  mortality  from 
1906  to  1 9 10  per  100,000  in  certain  American  cities: 


San  Francisco 102 

Boston 99 

Providence 96 

Los  Angeles 94 

Cincinnati 93 

Hartford 91 

New  Haven 89 

Dayton 88 

Rochester 88 

Springfield,  Mass 86 

District  of  Columbia. ...  86 

Baltimore 85 

Omaha 85 

Buffalo 84 

New  Orleans 82 

Philadelphia 81 

Hoboken 80 

Columbus 79 

Manhattan  and  Bronx.  .  78 

St.  Louis .  78 

Denver 77 


5  Newark 76.9 

4  Chicago 76.5 

9  Greater  New  York 74.1 

9  Richmond 73.9 

o  Kansas  City,  Mo 71.1 

9  St.  Paul 71. 1 

8  Indianapolis 7°-4 

5  Borough  of  Brooklyn..  .  .  68.9 
2  Milwaukee 68.4 

9  Nashville 68.0 

o  Pittsburgh 66.4 

8  Minneapolis 65.3 

7  Detroit 64.5 

o  Cleveland 62.9 

2  Louisville 61 . 1 

9  Jersey  City 60.  5 

7  Charleston 53.6 

5  Seattle s°-  2 

4  Augusta,  Ga 49 . 1 

4  Memphis 48.  7 

9  Savannah 47  . 1 


It  is  readily  understood  that  many  factors  enter  into  the 
study  and  proper  understanding  of  the  statistics  of  the  mortality 
of  cancer,  such  as  age,  sex,  location  of  the  lesion,  race,  etc.,  and 
it  is  quite  impossible  in  the  present  writing,  or  from  any  data 
accessible,  to  make  any  such  analysis  in  full,  but  a  few  points 
may  be  mentioned. 

Thus,  in  regard  to  age,  the  states  which  represented  the  great- 
est number  of  deaths  from  cancer — Maine  with  107.5;  New 
Hampshire,  107.3;  Vermont,  99.7  (114. 9  in  1916) — per  100,000, 
show  that  the  proportion  of  individuals  45  years  of  age  or  older 


MORTALITY  FROM  CANCER  225 

was  over  27  per  cent,  compared  with  17.7  per  cent  for  Kentucky 
and  16.2  per  cent  for  Montana,  which  latter  gave  almost  the 
lowest  mortality  for  cancer. 

The  same  is  somewhat  true  in  regard  to  sex,  although  suffi- 
cient data  are  not  at  hand  to  show  the  relative  number  of  males 
and  females  in  different  states.  Of  the  total  deaths  from  cancer 
in  the  United  States  in  1918,  38,619,  or  59.1  per  cent  were 
females,  and  26.721,  or  40.9  per  cent  males,  although  the  male 
population  in  the  registration  area  exceeds  the  female. 

We  know,  of  course,  that  the  great  preponderance  of 
deaths  from  cancer  in  females  is  due  to  the  disease  affecting 
the  breast  and  uterus,  and  where  females  preponderate  the 
total  cancer  mortality  would  be  higher.  The  general  mor- 
tality for  cancer  has  always  been  higher  in  females,  but  that 
of  males  is  steadily  gaining,  owing  it  is  thought  to  the  steady 
increase  of  deaths  from  cancer  of  the  stomach,  liver,  and 
intestines  in  males. 

The  location  of  the  lesion  has  also  a  bearing  upon  the  under- 
standing of  statistics.  Thus,  in  Norway,  for  some  unexplained 
reason,  cancer  of  the  stomach  seems  to  be  extremely  common. 
With  a  death  rate  from  cancer  in  general,  in  1912,  of  104.8  per 
100,000  inhabitants  (risen  from  50.6  in  1886),  there  is  reported 
by  Dr.  Soergaard  *  a  mortality  of  60  per  cent  of  all  to  be  from 
cancer  of  the  stomach,  while  those  from  the  breast  and  uterus 
are  very  few. 

In  the  United  States,  in  1918,  cancer  of  the  stomach  and  liver 
caused  the  death  of  23,845  persons,  of  these  12,208  were  males 
and  1 1,637  females.  The  total  cancer  deaths  were  25,780  males, 
of  which  almost  one-half  were  from  cancer  of  the  stomach  and 
liver,  and  36,379  females,  of  which  less  than  one-third  were 
from  this  cause.  Cancer  of  the  uterus  caused  8,043  deaths,  and 
that  of  the  breast,  6,040,  a  total  of  15,043,  or  41  per  cent  of  all 
the  cancer  deaths  in  females,  and  23  per  cent  of  all  deaths  from 
cancer  in  both  sexes. 

1  Soergaard,  "Die  Krebsform.  Norweg.  Zeitschr.  f.  Krebsforcsh."  1913 
(Hoffman,  p.  633). 

15 


226  CANCER 

Deaths  in  the  United  States  Registration  Area,  1918 


Age  of 
decedent 


Carcinoma 


Male       Female 


Sarcoma  Hyper-nephroma 


Male     I  Female  1     Male     I  Female 


All  ages. 


24,715 


36,780 


1,923 


1,795 


83 


44 


Under  1  year. 

1  year 

2  years 

3  years 

4  years 


13 

4 

19 

17 


22 
32 
26 
23 
19 


13 
17 
18 

20 
22 


Under  5  years 

5  to    9  years 

10  to  14  years 

to  19  years 

to  24  years 

to  29  years 

to  34  years 

to  39  years 

to  44  years 

to  49  years 

to  54  years 

to  59  years 

to  64  years 

to  69  years 

to  74  years 

to  79  years 

to  84  years 

to  89  years 

to  94  years 

to  99  years 

100  years  and  over. 
Unknown  age 


1 5 

20 
25 
30 
35 

40 

45 
SO 

55 
60 

65 
70 

75 
80 

85 
90 

95 


47 
27 

23 
34 
81 

155 

3°7 

611 

1,069 

1,711 

2,602 

3,201 

3,714 

3,759 

3,278 

2,246 

1,196 

481 

102 

27 

6 

38 


61 

28 

17 

43 

146 

386 

856 

1,626 

2,719 

3,738 

4,246 

4,695 

4,694 

4,566 

3,856 

2,686 

1,540 

613 

178 

27 

7 

52 


122 

44 

49 

75 

89 

in 

104 

126 

130 

131 

172 

210 

163 

141 

126 

70 

38 

19 


90 

41 

35 

65 

58 

75 

79 

96 

125 

167 

166 

156 

172 

154 

126 

109 

5i 

23 

6 


2 
2 
6 

15 
6 

14 
13 
12 

5 


Race  also  seems  to  have  something  to  do  with  the  mortality 
from  cancer,  although  as  statistics  develop,  it  is  seen  that  habits 
of  life  in  natives  modify  the  death  rate,  according  as  these  later 
approach  to  that  of  foreigners  with  whom  they  come  in  contact. 

Thus,  in  slavery  times  the  negroes  were  said  to  have  almost 
no  cancer,  when  they  lived  simple  lives  and  worked  hard.     But 


MORTALITY  FROM  CANCER  227 

since  their  freedom,  and  as  they  mingled  with  others,  serving 
in  hotels,  etc.,  the  death  rate  has  steadily  increased. 

In  studying  the  latest  Mortality  Tables  of  191 8,  it  is  rather 
surprising  to  find  that  in  New  York  City,  with  a  total  of  4,985 
deaths  from  cancer,  there  were  only  96  in  colored  persons:  of 
course  no  judgment  can  be  formed  from  this  without  knowing 
the  relative  number  of  the  latter  in  the  city,  which  cannot  be 
stated;  the  percentage  of  total  deaths  from  cancer,  among  the 
colored  is  always  very  much  lower  than  among  the  whites,  in 
every  state  but  one  in  which  they  are  recorded. 

The  Polynesians  and  Melanesians  seem  to  be  peculiarly 
exempt  from  cancer.  Sir  William  McGregor1,  although  he  had 
operated  several  times  for  cancer  in  whites  in  the  Fiji  Islands, 
never  remembers  operating  on  a  Polynesian  or  Melanesian, 
who  are  vegetarians.  He  never  saw  a  case  of  cancer  in  British 
Guiana  in  9^  years,  and  then  saw  an  encephaloid  cancer  of  the 
tibia  in  a  Papuan,  who  for  7  or  8  years  had  lived  practically  a 
European  life,  eating  canned  Australian  meat  daily. 

As  regards  Africa,  Williams  quotes  Dr.  Madden2  of  Cairo, 
who  says:  "The  consensus  of  opinion  among  medical  men  in 
Egypt  is,  that  cancer  is  never  found,  either  in  male  or  female, 
among  the  black  races  of  that  country.  These  include  the 
Berberines  and  the  Sudanese,  who  are  all  Musslemans,  and  live 
almost  entirely  on  vegetable  diet."  Of  19,529  deaths  among 
natives  of  Cairo  in  189 1,  only  19  were  due  to  cancer  (9  males  and 
10  females)  or  1  in  1,028,  while  in  England  during  the  same  year 
the  proportion  of  cancer  deaths  to  total  deaths  was  1  to  29. 
In  the  Islands  of  Lagos,  on  the  west  coast  of  Africa,  Dr.  John- 
son3 in  14  years'  practice  there  saw  five  cases  of  cancer  in  natives 
all  of  whom  lived  as  Europeans.  Renner4  reports  interestingly 
in  regard  to  cancer  among  the  descendants  of  liberated  Africans 
or  Creoles,  in  Sierre  Leone,  Africa.     During  30  years,  from  1870 

1  McGregor,  Brit.  Med.  Journ.,  1900,  ii,  p.  982. 

2  MADDEN-quoted  by  Williams,   p.  43,  Brit.  Med.  Journ.,   1902,  Vol.  2,   p. 

73°- 

3  Johnson,  Brit.  Med.  Journ.,  1900,  ii,  p.  982. 

4  Renner,  Brit.  Med.  Journ.,  1910,  ii,  p.  587;  also  1911,  i,  p.  no. 


228  CANCER 

to  1900,  there  were  but  30  cases  recorded  of  malignant  disease 
among  22,453  admitted  to  the  Colonial  Hospital:  in  the  next 
10  years  there  were  26  among  a  total  of  10,163,  a  sl°w  but 
steady  gain  in  cancer  incidence,  with  the  advancing  influence  of 
the  white  man.  More  of  this  evidence  will  be  found  in  other 
chapters,  and  we  need  not  dwell  on  it  longer  here. 

Realizing,  then,  that  the  mortality  of  cancer  is  materially 
and  steadily  rising,  in  spite  of  most  diligent  research  by  innum- 
erable honest  and  capable  scientists,  with  the  expenditure  of 
vast  sums  of  money  and  countless  animal  lives,  and  in  spite 
of  the  work  of  ardent,  earnest,  and  capable  surgeons,  to  whom 
all  honor  is  due,  but  who  have  failed  to  stay  the  terrible  progress 
of  the  disease,  let  us  briefly  study  some  of  the  reported  statistics 
in  regard  to  operative  interference  in  cancer. 

It  may  be  first  stated  that  this  is  a  most  difficult  task,  so 
different  are  the  reports  from  different  surgeons.  There  are 
many  elements  which  affect  the  statistics  relating  to  the  surgery 
of  cancer,  which  we  will  briefly  consider  in  turn. 

First,  as  to  the  stage  of  the  disease  at  which  the  operation  was 
performed.  We  have  tried  to  show  that  the  lesion  which  we 
call  real  cancer  is  but  the  result  of  a  deranged  blood  state, 
probably  of  long  existence,  and  that  the  whole  trouble  is  not  a 
purely  local  process,  a  something  simply  to  be  removed 
surgically  in  order  to  have  the  patient  get  well  and  remain  well. 
For  one  sees  plenty  of  cases  where  there  were  recurrences 
shortly  after  removal,  even  after  the  very  earliest  operations 
possible,  especially  on  the  breast  and  uterus.  But  the  claims 
put  forth  that  favorable  results  are  conditional  on  very  early 
operations  are  so  strenuous  and  persistent  that  we  must  perhaps 
believe  that  a  measure  of  the  favorable  results  claimed  can  be 
thus  accounted  for.  Though,  as  already  mentioned,  the  ex- 
cision of  lesions  which  were  pronounced  microscopically  not  to 
be  cancerous  have  been  followed  by  unmistakable  cancer.  We 
know,  of  course,  that  very  late  in  the  disease,  and  in  recurrences, 
operations  are  out  of  the  question,  and  commonly  harmful. 

It  is  a  little  curious,  however,  that  most  of  the  pictures 


SURGICAL  STATISTICS  OF  CANCER  229 

shown,  statistics  presented,  and  arguments  advanced  by  these 
advocates  of  early  operations,  relate  to  cutaneous  epithelioma, 
mainly  about  the  face,  which  cause  a  very  small  mortality, 
which  would  be  very  much  less  if  the  disease  were  properly  cared 
for  at  the  beginning,  for  their  early  recognition  is  relatively  easy. 
Moreover,  those  who  see  much  of  cutaneous  epithelioma  know 
that  if  rightly  handled  early,  it  is  generally  a  comparatively 
mild  affair  and  relatively  easily  cured  without  a  surgical 
operation,  as  by  #-ray,  radium,  certain  pastes,  etc.  And,  as 
already  mentioned,  it  is  excluded  in  our  present  study  of  cancer 
as  a  disease,  for  it  is  really  a  local  epithelial  degeneration  from 
external  causes.  But  mortality  statistics  are  greatly  influenced 
by  the  class  of  cases  which  an  operator  takes,  and  so  if  epithe- 
lioma of  the  skin  is  included  the  ratio  of  cures  will  be  higher. 
Selected  cases  also  always  give  more  favorable  statistics. 

Second,  the  knowledge  and  skill  of  the  operator,  and  the 
perfection  of  technique  undoubtedly  influence  surgical  statistics. 
The  ordinary  practitioner  or  surgeon  cannot  hope  for  as  favor- 
able results  in  many  operations  for  cancer  as  can  those  who  are 
past  masters  in  this  line,  and  these  latter  are  the  ones  who 
furnish  the  most  favorable  statistics. 

Third,  the  class  of  cases  operated  on  affect  surgical  statistics 
very  greatly.  While  cutaneous  epithelioma  of  the  face,  and 
even  of  the  lip,  when  well  removed,  may  yield  favorable  statis- 
tics, cancer  of  the  breast,  uterus,  stomach,  intestines,  gall 
bladder,  etc.,  still  yield  even  increasingly  unfavorable  statistics, 
as  will  be  presently  seen. 

Fourth,  the  duration  of  observation  after  operation  affects 
very  seriously  the  validity  of  statistics.  Not  long  ago  three 
years'  freedom  from  the  disease  was  considered  the  time  to 
regard  a  cancer  as  permanently  cured.  But  this  time  has 
been  lengthened  more  and  more,  by  the  observation  of  many 
cases  where  the  disease  has  recurred  even  long  afterwards, 
and  reliable  observers  are  now  very  chary  in  expressing  an 
opinion  as  to  the  final  cure  of  cancer;  and  some  surgeons,  as 
Deaver,  already  quoted,  say:  "We  still  do  nothing  to  cure  it." 


230  CANCER 

Finally,  the  optimism  of  the  reporter  seems  often  to  have 
something  to  do  with  the  reliability  of  surgical  statistics. 
This  need  hardly  be  discussed.  The  older  and  more  experi- 
enced the  surgeon,  the  less  confident  he  is  of  having  actually 
cured  cancer  with  the  knife.  At  a  discussion  on  cancer  in 
the  New  York  Academy  of  Medicine  some  years  ago,  Dr. 
Robert  F.  Weir  of  New  York,  said  that  the  late  Dr.  Agnew, 
a  celebrated  surgeon  of  Philadelphia,  had  remarked  just  before 
his  death  that  he  doubted  if  he  had  ever  been  justified  in  an 
operation  upon  cancer,  and  he,  Dr.  Weir,  stated  that  he  could 
almost  say  the  same.  At  a  recent  meeting  of  a  County  Medical 
Association  in  a  neighboring  city,  a  very  prominent  surgeon, 
60  years  old,  operating  over  a  wide  district,  said:  "Mr.  Presi- 
dent and  Gentlemen:  I  have  done  with  operations  on  cancer, 
and  hope  that  no  one  will  ever  ask  me  again  to  operate  on 
that  disease.  I  do  not  know  if  I  have  ever  done  enough  good 
to  warrant  the  operation."  A  very  prominent  anesthetist, 
who  has  had  a  very  great  deal  to  do  with  operations  on  cancer, 
remarked  to  me  recently  that  he  was  struck  with  the  unfortu- 
nate results  of  operations  on  the  disease.  Although  there  are 
still  occasional  records  of  cancer  operations  reported  as  success- 
ful, there  is  seldom  mention  of  observation  long  enough  to 
determine  if  the  disease  was  eradicated. 

Turning  now  to  the  actual  statistics  of  operative  surgery  on 
cancer,  we  will  find  that  the  percentage  of  reported  cures 
varies  greatly  in  accordance  with  the  points  just  stated.  It  is  un- 
derstood, of  course,  that  no  accurate  statements  can  be  made 
in  regard  to  the  actual  mortality  from  cancer  in  any  location, 
partly  owing  to  the  paucity  of  reliable  figures,  and  partly 
because  the  stages  and  extent  of  the  disease  differ  so  greatly 
in  different  cases,  and  the  final  results  vary  with  the  previous 
duration  of  the  disease  and  the  period  of  observation  after  the 
operation,  which  is  seldom  stated. 

Cancer  or  epithelioma  of  the  skin  presents  the  best  operative 
statistics  of  any  region,  and  the  claim  is  made  that  all  cases  are 
curable  if  operated  on  early  enough  and  rightly.     While  this  is 


SURGICAL  STATISTICS  OF  CANCER  231 

not  wholly  true,  it  is  certain  that  if  all  lesions  which  one  chooses 
to  call  "pre-cancerous"  are  thoroughly  extirpated  very  early, 
and  all  of  them  included  as  cancer  in  statistics,  the  percentage 
of  cures  can  be  reported  as  very  high.  So  that  it  may  be  said 
that,  taking  all  statistics  together,  including  very  small  as  well 
as  large  lesions,  the  favorable  results,  that  is  permanent  cures 
of  lesions  which  can  truly  be  called  cutaneous  epithelioma,  may, 
as  some  claim,  run  as  high  as  75  per  cent. 

But  against  this  is  set  the  fact  that  a  very  large  share  of  these 
cutaneous  epitheliomas  taken  early  and  treated  by  competent 
persons,  are  equally  amenable  to  lighter  measures,  without  the 
horrible  disfigurement  which  one  sometimes  sees  after  purely 
surgical  procedures. 

Cancer  of  the  lip,  when  treated  early,  and  skillfully,  and  radi- 
cally, including  sufficient  gland  extirpation,  also  yields  a  fairly 
satisfactory  result,  depending,  of  course,  on  the  duration  and 
stage  of  the  disease,  or  amount  of  involvement  of  tissue  and 
glands,  and  the  completeness  of  the  operation.  But  while  the 
lip  lesion  may  remain  absent,  subsequent  recurrence  in  deep 
glands  is  most  distressing  and  hopeless.  Thus,  while  some  oper- 
ators have  claimed  75  per  cent  of  cures,  Hertzler1  makes  the 
percentage  of  permanent  cure;  "not  much  over  25  per  cent," 
and  Taylor  agrees  that  this  is  approximately  correct,  if  all 
operations,  by  all  operators  were  taken  into  account.  And 
here  again,  it  may  be  remarked,  if  taken  early  and  treated 
correctly,  by  proper  local  and  constitutional  measures,  many 
of  these  cases  yield  without  the  knife,  as  will  be  seen  in  a  later 
chapter. 

When  we  come,  however,  to  cancer  within  the  mouth,  on  the 
tongue,  etc.,  it  is  quite  a  different  story,  as  mentioned  in  the 
chapter  on  prognosis,  and  the  end  results  of  surgery  are  com- 
monly unsatisfactory.  Certain  European  surgeons  have  reported 
an  operative  mortality  in  cancer  of  the  tongue  as  high  as  36  per 
cent,  while  recurrences  are  the  rule,  and  really  permanent  cures 

Hertzler,  "Treatise  on  Tumors"  quoted  by  Taylor,  "Cancer."     Phila. 
1915,  P-  193- 


232  CANCER 

the  very  great  exception.  Of  25  cases  reported  on  by  Steiner1 
there  were  9  operative  deaths,  or  36  per  cent.  Of  the  16  that 
recovered  from  the  operation  9  died  within  the  first  year,  4  cases 
in  the  second  year,  and  the  result  in  3  cases  was  unknown. 
Of  Steiner 's  25  cases  12,  or  nearly  50  per  cent,  were  operated  on 
within  the  first  3  months  of  the  apparent  onset  of  the  disease. 
Of  51  cases  reported  by  Erlich2  there  were  13  operative  deaths, 
or  over  25  per  cent,  and  but  five  cases  were  free  of  recurrence  at 
the  end  of  5  years. 

As  before  stated,  it  is  extremely  difficult  to  give  any  true  and 
accurate  estimate  of  the  real  end  results  from  operative  surgery, 
as  ordinarily  performed,  in  cancer  affecting  various  regions. 
The  obvious  reason  is  that  most  of  our  statistics  are  from  those 
who  are  especially  occupied  with  the  disease,  and  under  most 
favorable  hospital  facilities;  and  also  certain  statistics  may  be 
from  selected  cases.  Moreover,  operators  are  naturally  in- 
clined to  report  mainly  satisfactory  results,  and  that  also  too 
soon  after  operation  to  afford  a  just  and  fair  statement  of  end 
results,  while  the  unfavorable  aspects  are  seldom  fully  presented. 
Aside  then  from  superficial  epitheliomata,  about  the  only  loca- 
tion in  which  there  is  even  a  fair  chance  for  the  patient  under 
the  knife,  should  be  the  relatively  accessible  regions  of  the  breast, 
uterus,  intestines,  and  rectum,  and  for  these  large  statistics  are 
on  record;  but  again  these  are  unsatisfactory,  as  they  vary  so 
greatly. 

In  cancer  of  the  breast  the  statistics  are  very  provoking.  In- 
dividual operators  have  claimed  as  high  as  50  and  even  75  per 
cent  0/  cases  (Rodman).3  John  B.  Murphy,4  on  the  other  hand, 
on  the  basis  of  end  results,  states  that  the  plump  woman  invari- 
ably succumbs,  and  that  Paget's  disease  ends  fatally  in  90  per 
cent  of  the  cases. 

Hilderbrand  mentions  606  operations,  in  which  the  percent- 

1  Steiner,  Deutch.   Zeitschr.  f.  Chir.  Vol.  98.     Quoted  by  Taylor,  p.  182. 

2  Erlich,  Arch.  f.  Klin.  Chir.  Vol.  lxxviii.     Quoted  by  Taylor,  p.  182. 

3  Rodman.     Jour.  Amer.  Med.  Asso.,  Feb.  27,  1915. 

4  Murphy,  Clinics,  Aug.  12,  Aug.  19,  1913,  Dec.  12,  Sept.  14,  June  14. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  249 

survival  percentages  were  18  and  55  per  cent — the  latter  in  favor 
of  the  rayed  series.  Other  series  have  been  published  to  the 
same  effect. 

Next  to  prophylaxis  may  be  considered  recurrent  cancer,  but 
he  only  states  that  with  the  number  of  the  recurrences  the 
resistance  to  the  rays  increases.  The  first  recurrence  is  more 
amenable  to  treatment  than  the  second,  and  the  second  than  the 
third.  From  this  angle  the  possibility  of  keeping  the  patient 
alive  indefinitely  is  not  good. 

In  the  treatment  of  inoperable  cases  the  results  are  far  better 
than  was  once  the  case.  The  figures  of  Seitz  and  Wintz  are 
unusually  good,  amounting,  it  is  claimed,  to  50  per  cent  of  cures ; 
while  Duane  and  Greenough  report  55  per  cent  "improved." 
Sittenfeld  cannot  claim  such  good  results.  A  certain  per  cent 
are  brought  back  to  the  operable  stage.  In  the  treatment  of 
the  cachectic  patient,  which  is  practically  left  to  the  x-ray  men, 
failure  is  the  rule,  yet  now  and  then  a  result  is  obtained  in  the 
most  hopeless  cases,  which  is  encouraging.  There  is  daengr  that 
the  rays  may  injure  the  blood  cells  and,  hence,  frequent  blood 
tests  must  be  made. 

He  emphasizes  the  need  of  standardization  in  the  employ- 
ment of  x-rays,  this  includes  filtration,  focal  distance,  time, 
penetration  and  other  factors  affecting  both  the  quantity  and 
quality  of  the  rays. 

Sittenfeld  has  recently1  reported  very  interestingly  on  "New 
Roentgentherapy  in  Cancer,"  after  a  visit  to  several  medical 
centers  in  Germany.  He  states  that  the  technique  has  under- 
gone great  changes  there,  and  that  the  new  type  of  inductor  or 
transformer  develops  hard  rays  capable  of  penetrating  the 
entire  body.  Three  standard  types  of  tubes  are  now  in  use,  the 
Lilienfeld  tube,  the  Muller  Slide,  and  the  Furstenau  Coolidge 
tube.  These  led  to  the  study  of  accurate  measurement  of 
dosage  and  ray  absorption  in  the  deeper  tissues.  He  gives 
interesting  technical  details  and  also  clinical  data  of  value 
relating  to  work  in    Berlin,   Erlangen,   and  Freiburg,   which 

1  Sittenfeld,  Jonrn.  of  the  A.  M.  A.,  January  8,  1921. 


250  CANCER 

cannot  be  dwelt  upon  here,  but  which  seem  of  decided  impor- 
tance, and  he  speaks  of  the  results  obtained  as  astoundingly 
favorable.  At  the  Cancer  Institute  in  Berlin  he  saw  in  one 
day  35  patients  with  cancer  of  the  breast  who  had  reported 
for  observation,  who  had  been  radiated  2,  3,  or  4  years 
previously,  nearly  all  of  them  with  gratifying  results.  His 
reports  in  regard  to  cancer  of  the  uterus  at  Freiburg  were  also 
remarkable.  He  refers  the  advantage  to  more  powerful 
Roengten-ray  apparatus,  and  with  it  new  tubes  to  accept  a 
high-tension  voltage. 

Dr.  Stevens1  after  considering  surgery,  electric  heat  and 
the  value  of  the  .T-rays  for  the  lymphatics,  also  emphasizes 
the  crudeness  of  the  Roentgen  technique  at  the  hands  of  the 
average  practitioner  with  his  own  equipment.  With  many  of 
these  men  the  rays  are  primarily  for  radiography.  In  this 
kind  of  work  benefit  must  often  be  due  to  accident.  Again, 
a  good  picture  machine  may  be  quite  unsuited  for  raying 
malignant  growths.  Ordinary  gas  tubes  are  entirely  insuffi- 
cient for  deep  rayings,  which  require  a  Coolidge  tube,  a  special 
tube  holder,  etc.  A  Roentgen  specialist  naturally  has  to  give  his 
entire  time  to  his  specialty,  which  fact  militates  against  his  aqui- 
sition  of  knowlege  of  other  methods,  or  of  cancer  as  a  disease. 

Not  so  many  years  ago  the  methods  against  cancer  were 
very  simple  and  crude.  Diseased  tissues  were  cut  away 
regardless  of  the  site  or  character  of  the  tumor,  and  if  the  case 
was  frankly  inoperable,  either  nothing  was  done  at  all,  or  an 
attempt  was  made  to  give  some  relief  with  the  knife,  too  often 
with  sadly  unfortunate  results,  as  to  subsequent  pain  and 
length  of  life.  Today  a  merely  palliative  operation  is  seldom 
or  never  practiced,  because  it  is  known  to  hasten  the  end. 
The  if-ray  has  undoubtedly  done  much  good  in  many  directions, 
and  has  come  to  stay,  but  it  certainly  has  its  limitations  and 
it  is  futile  to  suppose  that  it  alone  can  ever  be  regarded  as  a 
cure  for  cancer,  any  more  than  can  surgery,  as  abundantly 
appears  elsewhere. 

1  Stevens,  Medical  Record,  November  13,  1920. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  251 

Radium. — We  will  now  consider  radium,  whose  rays  and 
action  many  consider  to  be  the  same,  or  much  the  same,  as 
those  of  the  x-ray,  but  which  has  shown  itself  to  be  of  much 
greater  service  in  malignant  disease  in  general,  for  reasons  which 
will  appear  in  its  consideration.  Unfortunately  by  the  unwise 
exploitation  of  some  operators,  its  powers  have  been  greatly  ex- 
aggerated, and  the  public  has  gotten  to  believe,  it  would  seem, 
that  it  has  miraculous  powers  against  cancer,  to  the  terrible 
disappointment  of  multitudes  of  sufferers.  At  the  best  its 
operation  is  only  local,  like  x-rays  and  surgery,  and  again  un- 
fortunately, the  mortality  rate  in  the  United  States  has  risen 
just  as  steadily  since  the  introduction  of  radium — and  in  New 
York  City,  where  it  is  probably  used  more  largely  than  any- 
where else,  the  increase  in  the  death  rate  from  cancer  is  still 
greater,  and  in  recent  weeks  has  even  exceeded  that  from 
tuberculosis. 

The  Memorial  Hospital  in  this  city,  which  now  has  probably 
the  largest  amount  of  radium  in  any  Institution,  has  for  6  years 
given  very  great  attention  to  this  line  of  treatment  of  cancer, 
and  with  a  very  large  clinic,  and  an  active  and  intelligent  staff 
of  workers  has  done  much  to  place  its  use  on  a  firm  basis  and 
to  formulate  and  demonstrate  the  most  satisfactory  modes  of  its 
employment;  though  all  acknowledge  that  there  is  need  yet  of 
far  greater  advance  before  its  true  value  and  the  proper 
technique  and  application  can  be  fully  established. 

In  191 7  there  was  published  a  book  on  "  Radium  Therapy 
in  Cancer  at  the  Memorial  Hospital  in  New  York,"  covering  the 
previous  2  years  of  its  use.  In  this  was  given  at  some  length 
an  interesting,  though  technical,  and  valuable  consideration  of 
the  "  Physical  Considerations  Relative  to  the  Application  of 
Radium,"  by  Dr.  Failla,  E.E.,  A.M.,  who  has  had  charge  of  the 
laboratory  and  the  physical  handling  of  the  element  from  the 
beginning  to  the  present  time,  and  to  whom,  I  believe,  much 
credit  is  due  for  its  successful  use — Dr.  H.  H.  Janeway  being 
director  of  the  radium  department  has  devised  and  directed 
the  actual  employment  of  the  same,  Dr.  Ewing  collaborating 


252  CANCER 

clinically  and  pathologically  in  the  hospital  work.  This  is 
not  the  place  to  enter  on  the  physics  of  radium  and  reference  to 
this  book  may  be  made. 

During  the  last  4  years  the  work  with  radium  has  been 
steadily  and  energetically  pushed,  with  a  very  large  amount 
of  material,  and  later  will  be  presented  material  regarding  the 
present  status  and  scope  of  radium  treatment  at  the  Memorial 
Hospital,  taken  from  the  manuscript  of  the  forthcoming  report 
of  the  Hospital,  kindly  loaned  by  Dr.  Janeway.  We  will  first 
consider  some  of  the  earlier  and  later  works  on  radium  by 
others,  which  have  combined  to  place  this  form  of  treatment  on 
its  present  basis.  Space  does  not  permit  of  going  very  far  back, 
nor  even  covering  a  tithe  of  the  material  which  could  be 
presented. 

Howard  Kelly,  writing  with  Dr.  Neill,  Jr.,1  says  that  he  has 
used  radium  for  over  1 1  years  and  claims  to  have  been  the  first 
to  cure  uterine  cancer  by  this  means.  This  was  a  recurrent 
uterine  cancer  in  a  patient  on  whom  he,  had  himself  operated 
for  the  same  the  year  before.  She  was  treated  for  3  weeks 
and  has  remained  well  since.  Since  that  time  he  has  worked 
with  Burnam,  Lewis,  Neill,  Jr.,  Robnett,  O'Brien,  and  Lants- 
berry.  During  this  time  he  has  seen  a  remarkable  change 
in  the  attitude  of  the  profession  toward  radium.  There  is 
fake  radium  in  the  market  he  says — which  may  explain  some 
non-successes — and  that  he  himself  has  been  victimized,  so 
that  all  radium  should  be  tested  before  use.  Large  quantities, 
from  half  a  gram  to  a  gram  and  a  half,  give  better  results  than 
smaller,  and  the  latter  are  known  to  be  dangerous.  He  men- 
tions using  now  the  emanation  in  minute  capillary  tubes,  such 
as  are  used  so  largely  in  the  Memorial  Hospital.  Kelly  states 
that  at  present  a  radium  expert  can  cure  a  cervical  cancer,  and 
he  and  John  Clark  are  committed  to  the  belief  that  5  years 
from  now  there  will  be  no  more  surgery  for  cancer  of  the  uterus. 
The  involved  parametria  and  outlying  nodules  may  be  felt 
through  the  rectum  and  radium  needles  or  emanation  may  be 

1  Kelly  and  Neill,  Jr.,  Amer.  Jonrn.  of  Surg.,  December,  1919. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  253 

carried  into  these  foci;  under  the  knife  recurrences  invariably 
begin  in  the  latter.  Recurrent  cancer  in  the  vaginal  vault,  he 
says,  is  "made  for  radium"  treatment,  and  when  seen  early 
enough  these  may  be  wiped  out,  never  to  return.  Routine 
examination  of  patients  may  therefore  help  to  treat  recurrences 
without  delay,  for  a  massive  recurrence  is  practically  incurable. 

Kelly  does  not  like  the  too  common  use  of  the  term  palliative 
treatment  in  connection  with  radium.  The  objective  is  cura- 
tive treatment  and  many  cures  have  been  accomplished,  to 
say  nothing  of  the  great  extension  of  life  in  some  so-called 
incurable  cases.  This  is  worthy  of  a  better  name  he  says,  than 
palliative,  which  seems  to  connote  relief  from  certain  symptoms. 
He  says  that  we  must  not  forget  that  radium  and  surgery  can 
do  team  work  in  individual  cases. 

In  the  American  Journal  of  Roentgenology  for  January,  1920 
are  clinical  papers  by  Clarke  and  Keene  of  Philadelphia  and 
Samuel  of  New  Orleans,  with  other  data  in  discussion  by  Stacy 
of  the  Mayo  clinic. 

Clarke  and  Keene  control  a  material  of  209  cases  of  cancer  of 
the  uterus  which  go  back  as  far  as  1913.  Of  this  n  1  patients 
are  known  to  have  died,  and  25  others  cannot  be  traced.  It 
is  known  that  73  are  still  living,  and  the  number  of  survivors 
have  steadily  increased,  year  by  year.  At  the  end  of  1914  there 
was  but  one  survivor  for  the  year,  while  there  were  34  survivors 
for  the  year  19 18  alone.  The  original  survivor  is  the  most  re- 
markable of  all,  for  the  woman  had  chorio-epithelioma  which 
had  ruptured  into  the  peritoneal  cavity.  Death  from  hemor- 
rhage was  averted  only  by  supra-vaginal  hysterectomy.  Six 
weeks  later  there  was  another  profuse  hemorrhage  from  the 
vagina,  the  growth  having  reappeared  as  a  large  fixed  mass  in 
the  left  side  of  the  pelvis.  Radium  was  applied  and  strange 
to  relate,  the  case  was  cured  and  remained  well  for  5  years. 

Samuels  of  New  Orleans  is  frankly  pessimistic.  He  does 
not  understand  why  his  results  were  not  as  good  as  those  of 
some  other  men.  He  tabulates  126  cases  of  cancer  of  the 
uterus.     But  a  small  number  are  alive  after  a  2-year  interval; 


254  CANCER 

all  apparently  did  well  for  the  first  8  to  1 2  months.  Recurrences 
cannot  be  treated  with  radium,  for  this  aggravates  them  in  the 
majority  of  cases.  At  the  end  of  the  quiescent  period,  when 
nothing  can  be  seen  or  felt,  the  woman  mentions  abdominal 
pain,  and  recurrence  is  found  to  follow.  Cases  in  which  the 
Perry  cautery  had  been  applied  did  not  do  well  under  radium. 

Stacy,  of  the  Mayo  clinic,  mentioned  a  series  of  79  cases  of 
cancer  of  the  uterus  treated  with  radium — of  these  54  have 
been  traced.  All  lived  longer  than  i}$  years  and  25  per 
cent  were  still  alive,  mostly  after  more  than  2  years.  In  the 
treatment  of  24  cases  of  recurrence  results  had  not  been  good. 
Of  16  traced,  three  are  living  after  from  2  to  3  years. 

Racasen1  began  the  radium  treatment  in  1913  and  has  had 
many  cases  of  3,  4,  and  5  year  cures.  But  in  30  to  40  per  cent 
of  his  400  cases  thus  treated  in  the  same  manner  radium  has 
failed,  and  he  is  seeking  for  the  reasons.  The  cases  sent  home 
to  die  had  sometimes  surprised  him  by  coming  back  to  the 
clinic  greatly  improved  and  even  at  times  clinically  cured;  in 
such  cases  there  had  been  evidently  a  cumulative  action  of  the 
radium.  As  accessory  measures  he  has  heated  the  splenic  area 
by  diathermy,  because  the  products  of  the  spleen  are  can- 
crolytic  and  leucocytosis  is  set  up.  He  has  also  injected 
colloidal  copper  into  the  vein  in  the  hope  of  making  the  growth 
more  radio-sensitive.  He  likewise  applied  copper  sulphate 
locally,  10  per  cent  before  radium  treatment  to  prevent  second- 
ary infection. 

In  breast  cancer,  a  field  where  some  experts  are  not  so  very 
sanguine,  Kelly  states  that  all  depends  upon  the  dose.  Spray- 
ing with  radium  is  enough  for  lymphosarcoma,  but  for  cancer 
we  must  have  intensive  treatment,  comparable  to  sledge 
hammer  blows,  inflicted  directly  on  the  lesion  in  the  breast. 
These  blows  must  follow  each  other  in  timed  succession,  al- 
ways on  the  proper  spot.  Herein  Kelly  presents  a  paradox. 
He  says  that  early  cancer  belongs  to  surgery,  while  utterly 
inoperable  cases  may  do  remarkably  well  under  radium.     Since 

1  Racasen,  Abstr.  from  Journ.  Amer.  Med.  Assn.,  April  16,  1920. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  255 

metastases  are  not  influenced  by  radium  the  authors  do  not 
attempt  treatment  if  there  are  intra-thoracic  deposits,  and 
mention  the  use  of  #-rays  only  in  connection  with  diagnosis. 

Young  and  Frontz1  of  Johns  Hopkins,  report  the  results  of 
treatment  of  66  cases  of  cancer  of  the  prostate.  There  is  no 
mention  of  total  figures,  but  in  12  cases,  three  which  received 
only  external  treatment  did  not  improve,  while  the  balance, 
in  which  radium  was  applied  both  externally  and  internally 
there  was  more  or  less  improvement. 

At  the  Radium  Institute  of  London  radium2  is  being  used  in  a 
most  conservative  manner. 

Operable  cancer  is  not  treated  there  at  all,  with  the  exception, 
of  course,  of  rodent  ulcer  and  the  few  cases  in  which  operation 
is  refused.  At  least  70  per  cent  of  the  cases  treated  are  very 
far  advanced,   with   extensive   dissemination  of   the   disease. 

About  20  to  25  per  cent  of  all  the  cancers  treated  are  mam- 
mary, including  all  varieties,  whether  acute  or  chronic.  Prog- 
nosis in  the  encephaloid  type  is  very  bad,  especially  in  the  young 
woman  of  corpulent  habit.  But  little  benefit  is  obtained  here 
— a  slight  retardation  has  been  seen  from  screening  the  peri- 
phery. In  the  chronic  atrophic  form  the  radium  strongly 
reinforces  Nature,  by  producing  the  so-called  curative  fibrosis. 
Between  these  two  extremes  all  gradations  are  seen,  and  the 
success  obtained  varies  with  the  amount  of  curative  fibrosis 
produced.  The  cancerous  alveoli  contract  and  the  cells  de- 
generate. 

The  percentage  of  cancer  of  the  uterus  is  not  given,  but 
apparently  these  cases  are  not  numerous  and  of  the  border  line 
type,  which  promise  the  patient  a  chance  of  benefit.  In  the 
inoperable  case  the  benefit  is  very  rapid  and  almost  always 
forthcoming.  The  growth  diminishes  in  size,  ulcers  heal, 
discharge  and  hemorrhage  cease  and  the  rate  of  growth  is 
slowed  up.  The  young  and  corpulent  do  badly,  and  results 
after   the   menopause   are   not   favorable.     Under   the   most 

1  Young  and  Frontz,   Journal  of  Urology,  Vol.  i,  p.  505. 

2  Radium,  September,  1920. 


256  CANCER 

favorable  conditions  the  progress  of  the  growth  is  arrested  and 
the  patient  may  survive,  3,  4,  5,  or  more  years,  but  she  cannot 
be  regarded  as  cured.  If  the  uterus  is  fixed,  with  extension  into 
the  parametria,  not  much  can  be  done.  Recurrence  in  the 
vagina  after  hysterectomy  sometimes  improves  remarkably. 
In  the  cauliflower  type  the  mass  must  first  be  excised.  To  get 
the  best  results  the  patient  should  be  around  50  years  of  age, 
with  intact  septa  between  the  bladder  and  rectum,  and  not 
much  periuterine  infiltration.  Of  intraoral  cases  the  greater 
number  are  in  an  advanced  stage  when  first  seen,  the  resources 
of  surgery  having  been  exhausted.  As  a  whole  the  results 
have  been  disappointing,  especially  in  ulcerated  cases.  Mas- 
sive implication  of  lymph-nodes  may  be  reduced  in  size,  and 
involvement  of  the  skin  and  ulceration  prevented. 

The  rectum  and  vagina  are  both  very  sensitive  to  the  action 
of  radium,  a  fact  which  must  interfere  somewhat  with  its  use. 
In  cancer  of  the  rectum  a  colostomy  must  as  a  rule  be  per- 
formed before  treatment  with  radium.  In  the  bladder,  espe- 
cially in  the  female,  good  results  are  obtainable,  largely  because 
the  radium  can  be  introduced  through  the  urethra  and  the 
bladder  may  also  be  treated  through  the  vagina. 

In  cancer  of  the  prostate  life  has  been  prolonged  for  2  or  3 
years  in  certain  cases.  In  cancer  of  the  oesophagus  relief, 
while  decided,  is  only  temporary.  In  the  stomach  radium  is 
now  used  by  allowing  the  patient  to  swallow  a  radium  tube 
held  by  a  string.     Results  are  not  stated. 

To  contrast  with  the  above  are  the  statements  of  a  radium 
expert  of  great  experience;  Boggs,1  who  is  a  prolific  writer, 
insists  that  there  should  be  specialists  in  malignant  disease  who 
should  not  be  wedded  to  any  one  plan  but  be  familiar  with  the 
indications  of  all.  If  there  is  an  immediate  recurrence  after  an 
apparent  radium  cure,  it  is  a  sign  that  some  technical  error 
has  been  committed.  Much  depends  on  a  smooth  and  even 
radium  scar,  which  should  be  pliable.  In  common  with  other 
radium  men  he  recommends  the  treatment  especially  for  cancer 

1  Boggs,  Journal  of  Radiology,  Jan.,  1920. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  257 

of  the  lower  lip.  In  its  first  stage  90  per  cent  recover  without 
deformity,  while  more  advanced  cases  are  curable  and  all  are 
benefited.  In  contrast  to  surgery  the  dreaded  scar  recurrence 
is  not  seen.  If  there  are  no  palpable  glands,  50  per  cent  of 
cases  recover  and  if  the  glands  are  palpable  25  per  cent  only, 
as  far  as  gland  recurrence  goes.  In  intraoral  cancer  brilliant 
results  have  been  seen,  while  others  are  disappointing.  If  the 
knife  is  used  radium  should  follow.  Boggs  recommends  associ- 
ated treatment  in  these  cases — electrocoagulation,  radium,  and 
#-rays. 

Since  but  1 5  per  cent  of  cancers  of  the  cervix  can  be  helped  by 
surgical  operation  there  should  be  a  field  for  radium  here.  In 
40  per  cent  of  operable  cancers  of  the  cervix  the  pelvic  lymph- 
nodes  are  not  involved,  while  in  inoperable  cases  the  per  cent 
involved  is  from  30  to  50.  Hence,  metastases  or  their  absence 
do  not  fix  the  indications,  and  the  pelvis  should  be  #-rayed  in 
every  case.  Of  late  radium  has  been  inserted  into  the  cervical 
canal  for  cancer  in  that  locality,  and  the  recurrences  so  common, 
in  knife  cases  are  not  seen  in  anything  like  the  same  frequency. 
Radium  will  clinically  cure  a  third  of  the  inoperable  cancers  of 
the  cervix  and  give  the  patient  two  or  three  years  of  health, 
but  sooner  or  later  recurrence  is  apt  to  occur.  In  the  incurable 
case  pain,  discharge  and  hemorrhage  may  be  arrested. 

Boggs  appears  to  prefer  heat  in  intraoral  and  pharyngeal 
cancer,  and  in  this  he  is  supported  by  numerous  London  special- 
ists, who  use  diathermy  in  preference  to  radium.  Boggs  recom- 
mends electrocoagulation  in  preference  to  the  knife,  because  the 
blood  vessels  are  not  opened  and  metastases  are  averted.  He 
even  prefers  #-rays  to  radium  in  the  oro-pharyngeal  cancer,  both 
per  se  and  when  used  with  heat.  He  would  always  use  the 
#-rays  when  ulceration  has  exposed  the  muscles. 

He  quotes  Schmidt,  who  states  that  while  radium  will  pre- 
serve life  for  2  or  3  years,  recurrence  usually  results,  although 
the  suffering  then  is  much  less  than  when  the  knife  has  been 
used.  Franck  of  Mt.  Sinai  uses  brief  intensive  radium  before 
excision  of  cervical  cancer,  and  then  goes  back  to  radium  again. 

17 


258  CANCER 

Boggs  has  in  the  past  19  years  seen  over  1,500  cases  of 
mammary  cancer  and  would  never  perform  the  ultraradical 
operation.  All  of  our  resources  put  together  are  not  solving 
the  problem  of  cancer  of  the  breast,  but  in  80  per  cent  of  cases 
radium  can  palliate,  with  prolongation  of  life  from  1  to  5  years. 
In  another  set  of  cases  surgery  and  radium  combined  are  useful. 
Since  the  introduction  of  radium  treatment  there  are  no  more 
morphine  eaters  among  those  thus  treated. 

In  1 91 7  Professor  Ewing1  collected  much  information  con- 
cerning the  results  of  radium  treatment  of  cancer.  He  has 
found  no  exaggerated  statements  of  benefit,  so  that  the  optim- 
ism of  the  public  was  not  inspired  by  the  medical  profession  who 
have  used  the  remedy. 

In  all  localities  where  the  knife  is  preeminently  unsatisfactory, 
as  the  cervix,  antrum  and  pharynx,  tongue,  prostate,  etc.,  the 
operability  should  have  its  limits  reduced,  and  radium  be  given 
a  trial.  But  to  overtreat  with  radium  causes  a  host  of  accidents 
— severe  and  profound  pain,  sloughing,  perforations,  infection 
and  intoxication.  It  is  claimed  that  areas  which  have  been 
exposed  to  radium  are  unfavorable  for  surgery.  Radium  is  a 
locally  acting  remedy  like  the  knife  and  can  never  be  regarded 
as  a  general  cure  for  cancer. 

In  regard  to  operability  and  the  treatment  of  operative  can- 
cer by  radium,  the  accumulated  evidence  seems  to  justify  its 
trial  in  the  early  and  circumscribed  case.  But  it  is  evident  that 
there  should  be  in  such  cases  some  special  contraindication  to 
the  use  of  the  knife.  On  account  of  the  great  mutilation  in 
operations  in  the  intraoral  and  certain  other  localities,  with  high 
operative  death  rate  in  some,  radium  might  be  a  substitute  for 
the  knife,  but  only  the  expert  radium  man  should  apply  this 
treatment.  The  matter  had  better  be  settled  at  once,  (appar- 
ently it  has  been  settled  in  favor  of  using  heat,  at  least  in  the 
minds  of  a  number  of  throat  surgeons).  The  cervix  uteri  is  a 
promising  field  for  radium  treatment  of  operable  cases,  and 
Ewing  believed  that  in  the  future  radium  will  be  used  in  certain 
1  Ewing,  Amer.  Journal  of  Roentg,  1918,  v.  413. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  259 

classes  of  early  and  localized  cancers.  There  are  conditions  of 
morale  to  be  considered.  Patients  are  not  afraid  of  radium  as 
they  are  of  the  knife,  and  do  not  procrastinate  so  much  when 
they  realize  the  circumstances.  The  medical  man  himself 
hesitates  on  the  same  account.  Again,  pre-cancerous  lesions 
in  great  variety  are  curable  by  radium,  and  the  hesitation  of  the 
patient  will  not  be  so  great,  for  the  prospect  of  surgical  removal 
of  warts,  moles,  polypi,  etc.,  favors  procrastination. 

Many  details  of  interest  should  be  generally  known.  Thus 
in  cancer  involving  bone,  radium  is  usually  resisted,  although 
this  is  by  no  means  a  contraindication  to  its  use  here.  Some 
radium  experts  are  looking  forward  to  a  deeper  action  of  radium 
and  a  greater  projection  of  its  rays  (Ewing  does  not  mention  the 
fact  that  the  #-rays  have  a  very  great  advantage  here). 

Ewing  has  never  personally  seen  the  phenomenon  of  the 
stimulation  of  cancer  cell  growth  by  weak  doses  of  radium, 
but  cites  a  few  who  claim  to  have  observed  this  result.  He 
gives  considerable  space  to  the  overdosage.  Granulation  tissue 
of  long  standing  heals  very  poorly  after  the  tumor  cells  have 
been  destroyed,  and  the  tumor  ought  by  rights  to  be  attacked 
before  there  is  much  accumulation  of  this  sort,  for  in  the  latter 
case  the  defense  reaction  of  the  connective  usually  set  up  by 
radium  does  not  occur.  This  dense  fibrous  tissue  appears  to 
interfere  with  the  destruction  of  the  cancer  cells  by  radium. 
When  this  kind  of  cicatricial  tissue  is  rayed,  an  indolent  ulcer 
is  apt  to  develop.  These  sores  will  not  heal  and  form  irritable 
areas  that  are  more  or  less  crippling  from  the  great  pain  and 
tenderness  which  may  coexist.  When  a  tumor  becomes  infected 
with  streptococci  radium  is  said  to  be  unable  to  cope  with  the 
situation,  which  antagonizes  also  the  success  of  the  treatment. 
The  early  history  of  radium  exhibition  shows  the  number  and 
variety  and  severity  of  the  accidents  caused. 

Cameron1  of  Pittsburgh  has  recently  published  notes  of 
interest  on  the  use  of  radiation  in  cancer.  He  goes  into  certain 
refinements  of  radium  selection.     The  supply  of  blood  to  the 

1  Cameron,  Radium,  Vol.  iv,  1914. 


260  CANCER 

area  and  its  lymphatic  drainage  capacity  must  be  considered. 
One  must  bear  in  mind  the  structure  and  embryological  origin 
of  the  tissues  involved,  for  there  is  a  special  response  in  each  of 
the  three  layers.  One  must  know  the  patient's  local  and 
constitutional  resistance  to  the  cancerous  invasion.  Especially 
within  the  mouth  one  is  apt  to  be  dealing  with  syphilis  as  well 
as  cancer.  One  may  be  able  to  increase  the  immunity,  but 
may  also  diminish  what  there  is  of  natural  immunity.  One 
has  to  deal  for  the  most  part  with  border  line,  advanced,  and 
terminal  cases,  and  there  has  usually  been  a  history  of  the  use 
of  various  remedies,  such  as  surgery,  caustic  pastes,  x-raying 
(perhaps  excessive),  etc.,  which  tends  to  alter  the  tissues  to  be 
treated. 

In  cancer  of  the  lip  one  should  know  whether  the  growth 
originated  on  the  mucous  or  cutaneous  surface.  Cancer  of  the 
buccal  surface  of  the  cheek  is  a  different  proposition  from  cancer 
of  the  antrum,  and  cancer  of  the  cervix  uteri  from  cancer  of  the 
fundus  of  the  same.  The  indication  for  radium  naturally 
involves  those  of  associated  methods,  as  electrocoagulation, 
x-rays,  etc.  Some  cases  do  best  under  radium  alone,  others 
under  radium  and  surgery,  others  again  under  x-rays  and 
radium  or  fulguration  and  radium. 

The  drawbacks  of  extensive  surgery  are  excessive  hemor- 
rhage, failure  to  close  blood  vessels,  failure  to  hinder  lymphatic 
drainage,  violent  handling  of  the  tumor,  prolonged  anesthesia 
and  of  course  great  mutilation,  high  primary  mortality,  and 
percentage  recurrence  despite  all  care  (with  the  evils  of  scar 
recurrence).  Radium  is  without  these  drawbacks.  Surgery 
removes  the  diseased  tissue  at  a  great  cosmetic  cost  and  radium 
does  the  same  without  cost  or  appreciable  loss  of  healthy  tissue. 
The  medical  man  would  doubtless  prefer  radium  for  a  member 
of  his  own  family.  Cameron  realizes  that  his  judgment  on 
the  proper  method  for  treating  cancer  of  the  cervix  will  antago- 
nize many  but  adheres  to  it — (but  is  open  to  statistical  proofs  to 
the  contrary). 

He  differs  from  some  authors  in  his  advice  to  build  up  th 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  261 

cancer  patient  by  diet  and  nourishing  food,  for  it  has  been 
claimed  that  to  give  such  patients  eggs  and  milk  is  like  feeding 
fire  with  fuel.  He  lays  stress  on  fresh  air,  rest  and  local  care 
of  the  lesion.  Indifference  to  the  local  lesion  is  incomprehen- 
sible and  favors  mixed  infection.  During  the  radium  reaction 
period  raw  surfaces  may  become  angry  and  the  patient  should 
be  warned.  We  must  avoid  burning  the  mucosa  of  the  mouth, 
although  this  is  well  nigh  impossible,  and  irritating  the  rectum 
and  vagina:  in  the  case  of  the  latter  a  gauze  pack  is  used  for 
distending  it  and  contains  the  radium  tubes:  the  bladder  is 
fitted  with  a  retention  catheter  to  prevent  its  distension.  In 
working  on  the  endometrium  a  persistent  discharge  may  be 
set  up,  and  in  the  case  of  the  cervix  extensive  radiations  may 
cause  adhesions  with  contractions.  Antiseptic  douches  are 
then  indicated.  With  low  white  cell  blood  count  in  cancer 
cases  smaller  doses  frequently  applied  are  substituted  for 
larger  ones,  in  a  few  prolonged  treatments.  Radium  in  the 
uterus  may  cause  nausea,  perhaps  as  a  reflex  from  the  uterus 
to  the  stomach. 

Side  by  side  with  successes  obtained  by  deep  radiation  should 
be  mentioned  others,  in  which  the  course  of  successful  raying  of 
uterine  fibroids  the  most  malignant  form  of  cancer  has  been 
roused  to  activity.  It  is  not  known  whether  the  cancer  growth 
originated  within  the  area  of  the  fibroid  as  an  example  of 
malignant  degeneration,  or  in  the  normal  intact  mucosa  of  the 
corpus  uteri.  Monnard1  reported  three  personal  cases  of  this 
type.  From  a  study  of  these  cases  there  can  be  little  doubt 
but  that  the  soft  rays  required  in  the  treatment  of  the  fibroid 
stimulated  latent  cancer  or  cancer-genetic  cells  to  furious 
proliferation.  The  malignity  was  so  intense  that  one  uterus 
became  fixed  in  72  hours.  The  same  consequences  might  occur 
in  any  locality  where  latent  cancer  cells  preexisted,  but  such 
cases  seem  to  be  very  rare,  and  it  is  said  by  authorities  that 
malignant  degeneration  of  fibroids  is  usually  acute. 

"  The  Mechanism  of  the  Action  of  Radium  on  Tumor  Tissue" 

1  Mornard,  Societe  de  Chirurgie,  1919,  xlv,  p.  1553. 


262  CANCER 

has  been  discussed  by  Levin.1  He  mentions  the  selective  action 
of  the  rays,  on  the  tumor-cells  which  is  in  no  sense  caustic. 
Side  by  side  with  the  degenerative  changes  in  the  cell  we  see  the 
connective-tissue  reaction.  To  determine  which  is  first, 
experiments  were  made  on  crown  gall  in  plants  where  a  connec- 
tive-tissue reaction  is  out  of  the  question.  The  rays  arrest  the 
growth  of  the  crown  gall  and  hence  the  action  on  tumor-cells  is 
no  doubt  a  direct  one.  These  cells  in  malignant  disease  are 
short  lived  and  before  they  undergo  spontaneous  degeneration 
the  usual  multiplication  into  two  daughter  cells  is  prevented. 
This  being  the  case  it  is  difficult  to  prove  that  the  degenerative 
changes  would  not  occur  of  themselves.  But  when  radium  is 
used  the  process  is  much  more  extensive  and  intensive.  An- 
other point,  when  the  cells  as  a  result  of  radium,  or  spontane- 
ously, lose  their  malignancy  through  inability  to  proliferate, 
the  connective-tissue  reaction  would  be  apt  to  occur  itself.  We 
see  this  illustrated  in  the  evolution  of  a  scirrhus  cancer;  and 
when  a  piece  of  cancer  is  implanted  in  the  tissues  the  connective- 
tissue  reaction  also  occurs.  But  in  speaking  of  sterilizing  the 
cells  and  thereby  preventing  proliferation  it  must  not  be 
forgotten  that  a  cell  may  be  merely  "stunned."  It  lives  in  a 
sort  of  suspended  animation  and  after  a  time  may  be  able  to 
proliferate.  Raying  normal  tissues  and  benign  tumors  never 
produces  a  connective-tissue  reaction,  so  that  there  is  a  direct 
connection  between  this  reaction  and  malignancy. 

In  a  bone  metastasis  we  may  also  see  a  connective-tissue 
reaction  characterized  by  the  formation  of  osteo-plastic  tissue. 
But  this  is  not  always  seen.  In  the  more  unfavorable  kind 
of  metastasis  there  is  no  new  bone  formed  and  on  the  contrary 
the  bone  is  rapidly  destroyed.  Levin  does  not  believe  that 
one  treatment  can  possibly  destroy  all  the  cancer  cells. 

Much  speculation  has  been  indulged  in,  in  regard  to  the 
mode  of  action  of  both  #-rays  and  radium,  some  of  it  is  probably 
correct,  some  may  be  modified  by  further  experience.  We  may 
quote  a  bit  from  the  article  of  Levin  previously  referred  to. 

1  Lenin,  Atner.  Journ.  of  Roentgenology,  November,  1920. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  263 

"The  action  of  radium  and  x-rays  when  analyzed  shows 
little  difference,  and  only  such  as  could  be  explained  by  the 
physical  difference  in  the  genesis  of  the  rays.  The  action  is 
exerted  both  on  the  tumor  and  on  the  connective  tissue.  On  the 
former  the  action  may  be  stimulating,  inhibiting  and  destruc- 
tive, while  on  the  latter  one  sees  both  stimulating  and  destruc- 
tive activity.  Moreover  in  acting  on  the  connective  tissue 
there  is  a  secondary  action  on  the  cells  which  attacks  them 
from  without.  In  other  words,  not  only  may  they  inhibit  or 
destroy  the  cells  directly  but  they  also  destroy  them  indirectly, 
through  the  contraction  of  the  new  fibro-plastic  connective 
tissue.  These  forms  of  activity  should  be  reviewed  in  more 
detail." 

The  stimulating  action  of  weak  rays  is  well  known,  and 
is  sufficient  to  cause  x-ray  cancer  of  the  skin  in  the  predisposed. 
There  is  no  doubt,  outside  of  this  class  of  cases,  that  soft  rays 
can  stimulate  cancer  or  cancer-genetic  cells  to  growth,  and  it 
has  been  the  great  aim  of  cancer  radiologists  to  eliminate  this 
danger  by  using  hard  rays  with  protective  screenings.  The 
danger  from  radium  seems  greater  in  the  clinic  than  the  danger 
from  x-rays,  which  latter  are  a  greater  menace  to  the  operator 
than  to  the  patient,  a  number  of  operators  having  died  from 
x-ray  burns.  But  that  rays  of  either  kind  may  do  harm  to 
patients  is  evident  from  the  cases  already  mentioned,  which 
could  be  reinforced  by  others. 

Next  to  the  stimulating  action  on  the  cells  should  be  men- 
tioned the  inhibitive,  or  to  use  a  more  expressive  term,  the 
sterilizing  action.  The  cancer  cell  is  notably  short  lived,  but 
breeds  rapidly  before  its  death.  The  rays  are  able  to  put  a  stop 
to  proliferation  without  causing  any  visible  change  in  the 
appearance  of  the  cell;  and  if  this  sterilizing  action  is  main- 
tained the  cancer  cells  may  die  a  natural  death,  without  having 
undergone  any  destruction.  Levin  and  Joseph  (loc.  cit.)  claim 
to  have  been  the  first  to  isolate  this  form  of  activity  of  radium 
in  human  cancer,  although  it  is  known  to  occur  in  experimental 
mouse  cancer.     It  is,  of  course,  understood  that  when  the  cells 


264  CANCER 

are  actually  destroyed  by  the  rays  the  sterilizing  action  must 
have  preceded  the  destructive  changes.  The  authors  call  this 
activity  clinical  inhibition,  because  the  growth  is  arrested  with- 
out actual  morphologic  change.  A  case  is  cited  of  a  cancer  of 
the  breast,  with  autopsy,  in  which  the  cancer  cells  showed  no 
morphological  change  and  no  metastases.  The  growth  which 
had  been  inoperable  was  completely  arrested  clinically.  The 
same  phenomena  were  studied  in  a  melanotic  cancer  with 
metastases,  the  progress  of  which  was  arrested  by  radium. 

Coming  to  the  destructive  action  on  the  cells,  the  morpho- 
logical changes  have  been  described  in  great  detail  by  many 
pathologists.  Such  changes  are  known  to  be  primary  and  not 
due  secondarily  to  the  effects  of  the  connective-tissue  reaction, 
but  since  both  processes  occur  side  by  side  it  is  not  a  simple 
matter  to  prove  the  existence  of  a  direct  destructive  action. 
Levin  and  Joseph  however  have  seen  the  evidence  of  direct 
action  long  before  the  secondary  changes.  In  rodent  ulcers, 
moreover,  the  cells  are  destroyed  without  any  connective- 
tissue  reaction.  In  the  latter  phenomenon  the  death  of  a  large 
number  of  cancer  cells  makes  it  possible  for  new  connective 
tissue  to  fill  the  void;  but  the  part  played  by  connective  tissue 
is  much  more  than  a  passive  one,  for  the  round  cell  infiltration 
becomes  organized  into  a  dense  connective  tissue  not  very 
vascular. 

This  sclerogenic  action  plays  a  great  role  in  walling  off  the 
cancer  from  the  sound  tissues,  and  in  isolating  and  strangling 
the  outlying  aggregations  of  cancer  cells.  It  works  hand  in 
hand  with  the  direct  destructive  action  upon  the  cells,  but  is,  in 
part,  of  inferior  potency,  because  the  microscope  shows  that 
intact  cancer  cells,  doubtless  able  to  awaken  to  activity,  are 
simply  held  in  latency.  A  merely  sterilizing  action  may  not  be 
permanent  and  the  claim  that  cancer  cells  are  shortlived  may 
not  exhaust  the  situation.  This  may  be  true  of  the  young  and 
actively  growing  cell,  but  there  is  much  evidence  that  cancer 
cells  may  awaken  after  years  of  latency,  as  in  those  cells  found 
at  times  in  the  margins  of  gastric  ulcers. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  265 

There  remains  only  for  mention  the  destructive  action  of  the 
rays  on  the  sound  tissues  from  high  doses,  which  is  tantamount 
to  destructive  burns,  followed  by  extensive  scarring.  The 
tissues  undergo  secondary  sloughing  and  the  defects  are  filled 
in  by  scar  tissue.  This  accident  is  not  uncommon  under 
unskilled  radium  treatment,  while  with  #-rays  the  caustic 
action  is  more  superficial. 

As  before  mentioned,  there  is  about  to  be  issued  a  report 
upon  "The  Present  Status  and  Scope  of  Radium  Therapy"  at 
the  Memorial  Hospital,  and  through  the  kindness  of  Dr. 
Janeway  I  have  been  able  to  see  the  manuscript  and  to  use  it  as 
desired.  This  represents  the  results  of  the  last  4  years  use  of 
this  remedy,  since  the  reports  of  the  first  2  years  work  was 
reported.  He  says  that  since  that  time  the  methods  formerly 
used  and  fully  described  in  that  publication  have  been  modified 
and  new  ones  developed.  Chief  among  these  is  the  imbedding 
of  practically  unfiltered  emanation  within  the  tumor  tissue. 
This  method  has  proved  so  useful  that  it  now  replaces  most  of 
the  methods  formerly  resorted  to  for  the  treatment  of  lesions 
of  the  mucous  membranes,  and  either  replaces  or  is  used  in 
conjunction  with  other  methods  in  the  treatment  of  many 
external  tumors. 

Also  during  the  past  four  years  well  supported  conclusions 
regarding  the  method  of  choice  for  different  lesions  and  regard- 
ing a  safe  and  efficient  dosage  have  been  reached;  in  other  words, 
standards  for  treatment  have  been  created  which  are  reliable, 
possibly  a  close  approach  to  the  best  standards  for  the  methods 
concerned.  Moreover,  a  knowledge  of  what  can  be  accom- 
plished by  radium  in  the  various  forms  and  stages  of  malignant 
growths  has  been  acquired,  so  that  a  very  accurate  prognosis 
can  now  be  given  at  the  start  of  the  treatment. 

This  knowledge,  attained  during  the  past  four  years  has  not 
been  acquired  sufficiently  early  to  make  it  of  much  value  to 
now  record  percentages  of  apparently  complete  retrogressions. 
The  period  covered  by  this  report,  like  that  covered  by  the 
preceding  one,  has  been  a  period  of  development;  an  attempt  to 


266  CANCER 

discover  just  what  radium  is  able  to  accomplish  in  the  cure  of 
cancer;  a  period  in  the  creation  of  methods  and  determination 
of  dosage;  and  of  determining  what  forms  of  cancer  can  be 
best  treated  by  its  use,  and  to  what  extent  benefited. 

Most  of  the  material  with  which  the  work  was  done — at 
first  almost  all,  and  even  now  most  of  it — must  be  classified  as 
the  deadwood  of  other  hospitals,  most  of  it  ignorantly  neglected 
or  unsuccessfully  operated  on  by  other  physicians  and  surgeons. 
A  report  of  percentage  of  cure  upon  material  of  this  character 
is  valueless.  In  the  future  cases  can  be  intelligently  classified 
at  the  start  of  treatment  from  a  standpoint  of  prognosis,  and  the 
proportion  of  cases  in  each  class  apparently  cured  or  benefited 
can  be  reported. 

The  report  states  that  the  results  of  treatment  of  malignant 
growths  by  radium  depend  so  much  on  the  method  of  applica- 
tion that  the  use  of  different  methods  of  application  may  be 
considered  really  as  the  use  of  different  therapeutical  agents. 
It  is  frequently  stated  in  surgical  literature,  in  regard  to  malig- 
nant tumors  of  practically  every  variety,  that  radium  has  been 
used  and  failed,  but  the  use  of  the  element,  often  in  indifferent 
ways  although  in  some  instances  good,  by  no  means  represents 
the  possibilities  which  may  be  obtained  by  this  agent,  any  more 
than  if  radium  had  not  been  used  at  all.  By  patient  trial  for 
the  past  6  years  of  one  method  after  another,  of  various  forms 
of  filtration,  of  different  dosage,  and  finally,  of  the  use  of  buried 
emanation,  the  efficiency  of  the  treatment  of  many  forms  of 
cancer  has  resulted  in  a  change  at  this  hospital,  which  justifies 
the  attending  staff  in  turning  over  to  radium  treatment  some 
operable  as  well  as  inoperable  varieties  of  many  malignant 
tumors.  The  treatment  of  operable  carcinoma  of  the  larynx  by 
radium  is  still  questioned:  but  the  concensus  of  opinion  is 
that  the  surgical  sacrifice  of  the  larynx  is  so  great  a  loss,  and 
the  results  already  obtained  by  radium  are  sufficiently  so 
good,  as  to  justify  its  use  before  laryngectomy.  They  justify 
their  use  of  radium  in  operable  cancer  of  the  rectum,  as  against 
the  frequent,  unfortunate  consequences  of  operation,  the  loss  of 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  267 

of  sphincter  control,  and  the  deplorable  condition  of  an  arti- 
ficial anus.  They  claim  much  for  radium  in  many  other  loca- 
tions, already  alluded  to,  but  state  that  the  evidence  cannot 
yet  be  based  upon  percentage  of  cures,  but  rather  on  results  of 
individual  cases,  and  upon  a  certain  regularity  with  which  such 
results  can  be  obtained. 

Their  view,  they  believe,  is  further  confirmed  by  a  comparison, 
especially  true  of  the  cases  in  the  border  line  of  operability,  of 
the  radium  successes  and  failures,  with  the  disabling  deformities 
of  surgical  successes,  and  the  pitiable  condition  of  surgical 
failures.  They  are  certain,  from  what  is  seen  at  the  Memorial 
Hospital  that  the  apparent  irresponsibility  and  the  freedom  with 
which  attempts  are  made  to  excise  cancer,  too  frequently  makes 
the  disease  immediately  worse  and  unfits  it  for  radium,  by 
which  it  should  have  been  first  treated  and  to  which  it  subse- 
quently comes,  after  it  is  too  late.  They  emphasize  the  import- 
ance of  the  type  of  malignant  growth  as  influencing  the  results 
of  any  kind  of  treatment,  and  remark  that  no  well  informed 
surgeon  would  today  operate  on  tumors  having  pronounced 
invasive  tendencies,  but  say  that  for  the  cure  of  these  cases  a 
general  remedy  must  be  awaited.  As  a  local  remedy,  radium 
where  successful,  undeniably  involves  far  less  initial  damage  and 
far  fewer  permanent  sacrifices  than  does  the  knife. 

In  regard  to  cancer  of  the  breast  they  state  that  in  operable 
tumors  which  have  refused  surgical  operation,  the  results  of 
radium  alone  or  combined  with  z-ray,  have  been  good  enough 
to  greatly  broaden  their  use  in  this  field;  as  only  4  per  cent  of 
carcinomas  of  the  breast,  when  surgically  attacked  after  involve- 
ment of  the  axillary  glands,  remain  well  for  any  length  of  time. 

The  report  goes  at  some  length  into  the  technical  principles 
employed  in  radium  therapy  at  the  Memorial  Hospital,  and 
refers  to  the  former  study  by  Dr.  Failla,  already  alluded  to. 
Considerable  attention  is  paid  to  the  employment  of  radium 
emanation  and  also  an  active  deposit  from  it,  instead  of  the 
substance  itself,  which  avoids  the  possible  loss  of  any  of  the 
radium  by  accident  or  theft.     It  is  believed  that  from   this 


268  CANCER 

active  deposit  are  derived  the  radiations  of  most  therapeutic 
value.  The  details  of  all  this  are  too  technical  and  lengthy  to 
be  given  here,  and  those  interested  are  referred  to  the  publica- 
tion previously  mentioned  and  the  report  of  the  Memorial 
Hospital  about  to  appear,  and  also  to  an  article  by  Dr.  Failla1 
giving  further  information  as  to  the  making  of  appliances, 
filtration,  and  measurement  of  dosage. 

Dr.  Janeway2  has  personally  reported  in  recent  years  upon 
cases  treated  with  radium,  which  may  be  briefly  alluded  to.  He 
gives  results  in  24  cases  of  cancer  of  the  lip  treated  by  this 
means.  There  was  one  series  of  six  cases  with  cancer  of  the  lip 
during  the  years  1915  and  1916.  One  had  not  been  traced,  and 
there  had  been  but  one  recurrence  up  to  January  1,  1918.  The 
remainder,  18  had  all  been  treated  within  a  year,  and  three  have 
died,  all  advanced  cases.  He  believes  that  results  justify  the 
use  of  radium  in  operable  lower  lip  cases,  especially  if  taken 
early.  If  lymphatic  nodes  have  already  formed  it  is  best  to 
dissect  them  out  and  use  radium  in  the  wound.  The  emanation 
is  recommended  filtered  through  the  thinnest  material,  as  1  mm. 
of  platinum,  or  enclosed  in  0.5  mm.  of  silver  for  other  work. 

Later3  he  reported  on  four  patients  with  cancer  of  the  uterus 
treated  with  radium,  one  of  whom  was  apparently  well  2  years 
after  treatment,  one  was  well  1  year  after  treatment,  one  well 
for  2  years,  when  recurrence  and  metastases  occurred,  and  the 
fourth  did  not  improve.  Glass  emanation  tubes,  unfiltered, 
were  imbedded  in  the  mass,  while  filtered  tubes  were  also  used. 

Dr.  Janeway4  about  the  same  time  made  a  remarkable  study 
on  the  treatment  of  uterine  cancer  by  radium  which  is  worthy 
of  most  careful  attention,  as  he  gives  a  careful  analysis  of  surgi- 
cal results  and  a  full  study  of  reports  on  the  use  of  radium  by 
many  observers,  with  a  very  extensive  bibliography.  He  gives 
careful  histories  of  30  cases,  of  which  there  were  17  cases  of  car- 

1  Failla,  Radium  technique,  etc.     Radium,  June,  1920. 

2  Janeway,  Journ.  Amer.  Med.  Assn.,  April  13,  1918. 
'Janeway,  Radium,  November,  1919. 

4  Janeway,  Surgery,  Gynecology  and  Obstetrics.     September,  1919. 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  269 

cinoma  of  the  cervix,  and  of  these  1 2  clinically  cured,  3^  years 
to  6  months  after  treatment:  four  cases  of  recurrent  carcinoma 
of  the  crevix,  2  clinically  cured  16  and  25  months  after  treat- 
ment, one  improved;  four  cases  of  carcinoma  of  the  fundus,  two 
improved  for  a  period  of  2  years,  and  two  clinically  cured:  and 
five  cases  of  carcinoma  of  the  external  genitals,  three  clinically 
cured  21  to  16  months  after  treatment,  1  improved,  1  unim- 
proved. 

While  there  were  some  recurrences,  even  shortly  after  the  use 
of  radium,  he  says  that  "Our  present  evidence  indicates  that 
radium  destroys  the  disease  at  this  site  to  a  greater  distance  than 
the  knife  is  capable  of  removing  it,  and  does  this  with  no  risk  or 
inconvenience  to  the  patient  and  only  a  small  tax  on  the  skill 
of  the  surgeon," 

Two  cases  of  cancer  of  the  tongue  treated  with  radium1 
are  reported  by  him.  The  first  patient,  a  woman  of  36  had 
pyorrhoea  and  several  ulcers  on  the  tongue.  Two  of  these  on 
the  tip  healed  spontaneously,  but  one  on  the  right  margin  grew 
worse,  showing  the  character  of  malignancy,  and  the  microscope 
showed  epidermoid  cancer.  There  was  but  slight  infiltration 
and  no  lymph-node  hyperplasia.  Three  small  tubes  were 
buried  directly  in  the  ulcer  and  others  applied  directly  upon  it 
in  a  mold  of  dental  modelling  compound,  for  an  hour  only. 
In  3  weeks  there  was  no  trace  of  the  lesion.  Another  patient, 
a  man  of  70,  heavy  smoker,  no  teeth,  had  a  small  ulcer  on  the 
right  side  of  the  tongue  for  18  months,  increasing  slowly  and 
becoming  painful;  base  was  slightly  indurated,  but  there  was 
no  mention  of  adenopathy,  nor  of  biopsy.  The  radium  was 
applied  by  means  of  a  dental  molding  for  2  hours,  and  glass 
tubes  embedded  in  the  floor.  The  ulcer  healed,  but  left  an 
induration  which  was  treated  by  embedding,  and  there  was  no 
evidence  of  the  disease  three  months  later. 

There  was  also  reported  the  case  of  a  man  with  cancer  of 
the  right  tonsil  with  infiltration  of  deep  nodes,  clinically  cured 
with  one  treatment  of  buried  emanation.     There  was  micro- 

1  Janeway,  Amer.  Joum.  of  Radiology,  February,  1920. 


270  CANCER 

scopic  diagnosis.  Six  tubes  were  embedded  in  the  mass,  and 
healing  followed  with  complete  disappearance  of  the  mass, 
and  eventually  the  swelling  of  the  lymph  nodes  vanished. 
A  case  of  primary  carcinoma  of  the  antrum  in  a  woman  aged 
59  was  reported,  clinically  cured  by  one  treatment  of  unfiltered 
radium.  There  was  a  swelling  of  the  right  cheek,  and  within 
the  mouth  the  superior  alveolar  process  of  the  right  side  was 
felt  to  be  swollen,  suggesting  downward  displacement  of  the 
antrum.  In  the  bucco  -  gingival  sulcus  there  protruded  a 
small  ulcerated  mass  breaking  through  from  the  cavity.  The 
microscope  revealed  epithelioma.  The  external  carotids  were 
ligated  on  both  sides  of  the  neck,  and  the  right  antral  cavity 
laid  open  by  removing  the  superior  alveolar  process.  Fifty 
millicuries,  unfiltered,  in  glass  tubes  were  placed  in  the  center 
of  the  antrum  and  surrounded  by  packing  and  left  in  place 
48  hours.  The  operation  was  followed  by  radium  inflammation 
and  an  attack  of  lobar  pneumonia,  but  she  recovered. 

In  writing  and  studying  these  and  other  accounts  of  the 
action  of  a'-rays  and  radium  in  malignant  disease,  one  is  struck 
by  several  points  presented: 

1.  The  claim  that  both  are  similar  in  action,  requiring  only 
a  better  understanding,  especially  in  regard  to  the  former,  of 
the  strength,  modes  of  application,  filtering,  dosage,  etc. 

2.  That  many  observers  recognize  that  both  methods  of 
radiation  are  only  local  measures,  like  the  knife,  and  that  one 
cannot  expect  thereby  to  cure  the  disease  permanently ;  one  of 
them  at  least  speaks  of  looking  for  a  general  remedy  to  reach 
certain  cases. 

3.  All  recognize  that  much  involvement  of  lymphatic  glands, 
or  metastases,  precludes  expectation  of  permanent  success. 

4.  Very  many  emphasize  the  grave  imperfection  of  much 
that  is  done  by  inexperienced  workers,  and  the  great  necessity 
of    standardization    as  to  equipment,  filtration,  dosage,  etc. 

Looking  over  all  the  reports  that  have  been  given  here 
and  elsewhere,  one  cannot  help  feeling  things  that,  as  with 


X-RAY  AND  RADIUM  TREATMENT  OF  CANCER  271 

surgery,  we  are  still  on  the  wrong  track  as  to  the  real  nature 
and  proper  treatment  of  the  disease  carcinoma.  As  in  the 
past,  so  at  present,  the  eyes  of  the  profession  and  the  laiety  are 
directed  solely  to  the  local  manifestations  or  product  of  the 
disease,  and  not  at  its  true  nature,  as  has  been  shown  in  other 
pages.  The  mere  removal  of  the  affected  area,  and  its  sur- 
roundings by  surgery,  or  their  disappearance  under  z-rays  or 
radium,  leaves  unnoticed  and  uncared  for  the  basic  cause  of  the 
new  formation,  and  this  is  very  likely  to  be  reproduced  some- 
where, as  all  recognize,  if  the  original  causes  are  still  at  work. 
Even  Ewing1  from  a  pathological  standpoint,  says  "by  far  the 
most  important  element  "(speaking  of  cancer  of  the  breast)" 
"  is  chronic  productive  mastitis.  The  great  majority  of  cancers 
develop  in  organs  altered  by  reactive  inflammatory  processes. 
Minute  histological  analysis  of  the  conditions  surrounding  the 
beginnings  of  cancer  in  chronic  mastitis  point  to  mechanical 
isolation  of  cell  groups  in  fibro-carcinoma,  and  irritation  by 
chemically  altered  secretion  and  exudate  in  adeno-carcinoma,  as 
the  immediate  precursor  of  a  typical  overgrowth  .  .  .  the  disease 
is  satisfactorily  accounted  for  as  the  liberation  of  growth 
tendencies  of  overnourished  and  proliferating  cells," — and  as 
has  been  mentioned  elsewhere,  he  frequently  refers  to  deranged 
nourishment  as  a  cause  of  malignant  growths,  which  latter  is 
the  entire  basis  of  our  thesis  in  regard  to  the  nature  and  proper 
treatment  of  cancer. 

Several  of  the  authors  on  x-ray  and  radium  realizing  that 
these  play  only  a  secondary  part  in  the  real  treatment  of  cancer, 
urge  that  the  specialist  in  malignant  disease  be  not  wedded 
to  any  one  plan  of  treatment,  but  that  he  be  familiar  with 
all,  and  employ  them  as  necessity  requires,  and  should  the 
dietetic,  hygienic,  and  medicinal  treatment  of  cancer  become 
generally  adopted,  medico-radiation  should  and  probably  will 
form  a  valuable  adjunct  in  attacking  and  modifying  the  local 
products  of  the  disease. 

1  Ewing,  "Neoplastic  Diseases."    Philadelphia,  1919,  p.  490. 


CHAPTER  XVI 
BIO-THERAPY  OF  CANCER 

This  is  a  large  and  important  subject  which  may,  by  con- 
tinued scientific  research  and  clinical  experience,  result  in  a 
material  advance  in  the  control  of  cancer,  but  which  at  present 
is  considered  with  suspicion  or  doubt  by  a  large  share  of  the 
medical  profession,  especially  by  the  surgeons.  There  is  no 
reason,  however,  why  ultimately  such  treatment  may  not 
confirm  and  support  the  thesis  of  the  constitutional  nature  and 
medical  therapeutics  of  cancer,  and  why  it  may  not,  when 
perfected,  be  a  rational  and  efficient  aid  in  the  treatment 
advocated  in  these  pages. 

The  lines  along  which  attempts  have  been  made  for  what 
has  been  called  the  biological  treatment  of  cancer  are  many  and 
varied,  and  cannot  and  need  not  all  be  considered  here.  It  is 
difficult  indeed  even  to  classify  them,  as  they  are  of  such 
different  characters,  based  upon  quite  different  ideas  or  theories 
regarding  the  nature  and  cause  of  the  disease,  some  of  them 
quite  bizarre  and  erroneous.  Literature  is  full  of  reports  of 
various ;  experiments  and  studies,  scientific  and  other,  which 
have  been  made,  largely  unsuccessfully,  with  substances  of  all 
kinds,  and  the  nomenclature  advanced  has  been  about  as  wild 
and  confusing  as  some  of  the  theories. 

The  various  solutions  which  have  been  employed  and  tested 
parenterally,  by  intravenous  or  subcutaneous  injections,  may 
possibly  be  best  grouped  under  three  headings,  (i)  Bacterial, 
(2)  Serous,  including  human  and  animal  substances,  and  (3) 
Cytolytic,  from  vegetable  substances,  and  with  all  of  them  the 
proposer  or  advocates  have  claimed  some  measure  of  success, 
though  often  slight,  in  the  cure  of  cancer.     To  these  should 

272 


BIO-THERAPY  OF  CANCER  273 

perhaps  be  added  (4)  Organotherapy,  relating  to  the  employ- 
ment, generally  by  the  stomach,  though  often  otherwise,  of 
preparations  of  the  endocrinous  glands  of  animals,  in  one  or 
another  form.  It  would  carry  us  far  beyond  the  practical 
purpose  of  this  writing  to  consider  separately,  or  even  to 
mention  the  name  and  composition  of  the  various  solutions 
or  mixtures  which  have  been  employed  in  connection  with  the 
bio-therapy  of  cancer.  But  it  is  interesting,  in  relation  to  our 
studies  regarding  erroneous  protein  metabolism  in  cancer,  to 
note  that  all  of  these  preparations  used  parenterally,  or  most  of 
them,  contain  a  protein  substance  which  is  foreign  to  that  ordin- 
arily taken  as  food.  Later  we  will  see  the  basis  of  their  action 
in  modifying  the  protein  relations  in  carcinoma. 

Some  years  ago  Ewing1  made  a  careful  study  of  "The 
Treatment  of  Cancer  on  Bio-logical  Principles,"  giving  a 
summary  of  sero-therapy  to  date,  including  auto-  and  vaccino- 
therapy, and  we  cannot  better  introduce  the  subject  than  by 
freely  abstracting  from  the  same.  For  we  must  recognize  that 
while  some  of  them  were  based  on  wrong  conceptions  of  the 
parasitic  nature  of  cancer,  or  on  erroneous  theories,  the  experi- 
ments and  trials  of  various  means  were  made  mainly  by  honest 
and  often  very  skillful  investigators,  in  the  earnest  desire  to 
find  some  means  of  overcoming  this  dire  disease,  which  surgery 
failed  to  control. 

Toxin  Therapy,  Vaccinotherapy,  Etc. — That  so  many  dif- 
ferent procedures  seem  to  have  been  of  temporary  value,  at 
least,  in  some  cases  is  a  fact  worthy  of  attention  and  analysis. 
The  benefit  in  these  cases  should  not  be  too  hastily  explained 
away.  It  is  of  course  possible  that  simple  measures  like  asepsis 
may  be  responsible  for  slight  improvement.  But  in  the  case  of 
thyroid  extract  we  have  a  substance  that  has  repeatedly  led 
to  regressive  changes  in  cancer,  although  it  is  not  a  remedy  in 
the  ordinary  sense.  If  we  could  learn  the  secret  of  this  benefit, 
it  might  aid  us  in  our  general  work  in  the  research  for  a  genuine 
or  specific  remedy.     In  the  same  connection  the  author  would 

1  Ewing,  New  York  Medical  Journal,  October  12,  1912. 

18 


274  CANCER 

place  arsenic.  Even  recently  Czerny  had  noted  that  certain 
cases  improve  under  injections  of  salvarsan. 

Toxin  therapy  is  of  course  different  from  sero-therapy,  yet 
some  of  the  sera  contain  toxic  substances.  At  the  time  of 
writing  Coley's  toxin  treatment  had  been  efficacious  only 
against  sarcoma,  but  since  the  appearance  of  E wing's  article, 
at  least  one  cancer  has  been  cured  by  this  method,  and  Coley 
has  recently  reported  it.  Under  toxin  treatment  come  those 
of  Doyen,  San  Felice,  and  Schmidt.  The  first  named  had  as  a 
basis  the  activities  of  a  micrococcus  {m.  neoformans) ,  the  second 
used  the  blastomyces,  and  the  third  a  mould.  Ewing  does  not 
pause  for  details,  here,  but  classes  all  the  preceding  under  a  com- 
mon head.  The  active  principle  is  secreted  by  the  micro- 
organisms and  is  toxic  enough  to  cause  fever  and  general 
intoxication.  Vidal  lays  stress  on  the  fever-producing  proper- 
ties. In  addition  to  the  three  just  enumerated  and  Coley's 
serum,  a  streptococcus  serum  was  used  with  the  same  kind  of 
result  by  Emmerich  and  School.  The  tumors  show  regression, 
but  as  a  rule  this  is  limited.  Small  tumors  may  disappear. 
The  growing  edge  resists  treatment  much  more  than  the  center, 
which  is  often  in  a  stage  of  softening. 

The  treatment  of  inoperable  sarcoma  by  the  mixed  toxins  of 
erysipelas  and  bacillus  prodigiosus,  introduced  by  Dr.  William 
B.  Coley  in  1893,  and  of  which  a  description  of  the  method  and 
the  early  results,  was  published  a  year  later,1  deserves  special 
mention,  as  increasing  years  to  the  present  time  have  estab- 
lished its  value  in  many  cases  of  the  too  often  hopeless  disease, 
sarcoma.  Dr.  Coley  has  repeatedly  written  on  the  subject,  and 
for  its  proper  understandings  a  number  of  references  are  here 
given.  There  is  no  apparent  reason  why  '  Coley's  serum" 
may  not  be  of  value  in  connection  with  other  proper  dietetic 
and  medical  treatment. 

This  method  was  an  outgrowth  of  a  year's  experience  in 
treating  inoperable  malignant  tumors  with  the  living  cultures 

1  Transaction  Amer.  Surg.  Ass'n.,  1894,  and  Amer.  Jour,  of  Med.  Sciences, 
July,  1894. 


BIO-THERAPY  OF  CANCER  275 

of  the  streptococcus  of  erysipelas,  suggested  by  a  considerable 
number  of  clinical  observations  recorded  in  the  literature,  in 
which  malignant  tumors,  particularly  sarcoma,  had  disap- 
peared during  or  immediately  after  an  intercurrent  attack  of 
erysipelas.1  Dr.  Coley's  later  results,  published  in  1913,  may 
be  found  in  the  Transactions  of  the  Third  International  Cancer 
Research  Conference,  Brussels,  of  that  year.  His  greatest 
success  with  the  toxins  has  been  in  sarcoma  of  the  long  bones. 
For  many  years  he  has  constantly  advocated  the  conservative 
treatment  of  sarcoma  of  the  long  bones,  in  spite  of  the  almost 
universal  surgical  practice  of  immediate  amputation  as  soon 
as  the  diagnosis  was  made,  and  in  a  recent  paper  on  the  sub- 
ject2 he  reported  250  personal  cases  of  this  type.  Although  in 
a  large  proportion  of  these,  the  disease  was  far  advanced  and 
the  condition  practically  hopeless  at  the  time  of  observation,  3 1 
patients  have  remained  well  for  a  period  of  more  than  3  years; 
in  1 5  of  these  the  tumor  was  of  the  periosteal  type,  a  type  very 
rarely  cured  by  high  amputation.  Up  to  the  present  time  Dr. 
Coley  has  had  17  cases  of  sarcoma  of  the  long  bones  in  which 
the  limb  has  been  saved,  in  n  of  which  the  toxins  alone  or 
toxins  and  curetting  were  used,  and  in  6,  the  toxins  supple- 
mented by  radium,  or  radium  and  #-ray.3 

Theoretically  there  are  strong  grounds  for  advising  the  use  of 
the  toxins  after  operation  for  sarcoma — and  often-times  after 
operation  for  carcinoma  and  melanoma — as  a  prophylactic 
measure  against  recurrence.  This  use  of  the  toxins  has  been 
strongly  advocated  by  Dr.  Howard  Lilienthal  for  many  years. 
While  there  are  no  large  series  of  cases  yet  published  to  defi- 
nitely prove  the  value  of  this  procedure,  there  are  a  certain 
amount  of  data  that  support  this  view.  It  is  generally  recog- 
nized that  nearly  all  cases  of  sarcoma  or  teratoma  of  the  testis 
recur  after  operation,  causing  death  in  1-3  years.  Dr.  Coley 
has  now  8  cases  of  sarcoma  of  the  testis  (one  a  highly  malignant, 

1  Amer.  Jour,  of  Medical  Sciences,  March,  1906. 

2  Transactions  of  the  Amer.  Surg.  Ass'n.,  1919. 
3 Proceedings  Royal  Society  of  Medicine,  1909. 


276  CANCER 

3-times  recurrent  in  three  months)  in  which  the  toxins  were 
used  after  operation,  and  the  patients  are  still  free  from  recur- 
rence 3-12  years  after.  In  nearly  100  cases  of  sarcoma  of  the 
clavicle  treated  by  total  excision,  reported  in  the  literature, 
only  5  were  apparently  cured  by  operation,  while  in  5  cases  in 
which  the  toxins  were  given  in  conjunction  with  excision,  4  of 
the  patients  have  remained  well  from  6-12  years  after. 

As  regards  the  use  of  the  toxins  in  melanotic  sarcoma  or  mela- 
noma. This  type  of  malignant  disease  is  the  most  hopeless  of 
all  from  any  form  of  treatment.  Almost  no  cases  have  been 
cured  by  surgery  alone.  X-ray  and  radium  have  cured  few 
if  any  cases.  Dr.  Coley  has  reported  5  cases  apparently  cured 
by  the  toxins.1  Three  of  these  were  inoperable,  i.e.,  1,  the 
Greenwood  case  of  Leeds,  England  (well  now  10  years);  2nd, 
the  Lilienthal  case,  chestwall  involving  the  ribs  (well  10  years) ; 
3rd  Coley 's  case,  neck,  inoperable  recurrence  (well  6}i  years). 
In  the  other  cases  the  toxins  were  given  after  operation  and  the 
patient  are  well  over  10  years.  Coley  believes  that  every 
melanotic  sarcoma  should  be  removed  as  early  and  widely  as 
possible  and  then  given  prolonged  toxin  treatment  for  6  months 
to  1  year.2  Local  treatment  of  the  operative  area  and  nearest 
glandular  fields  with  radium  or  X-ray  should  be  given. 

Another  important  field  for  the  toxins,  in  Dr.  Coley's  opinion, 
is  that  of  lymphosarcoma  in  which  thus  far,  surgery  has  been 
practically  of  no  avail  and  the  often  very  brilliant  results  from 
radium  or  x-ray  have  for  the  most  part  proved  temporary. 
In  his  paper  on  Primary  Neoplasms  of  the  Lymphatic  Glands, 
including  Hodgkin's  Disease.3  Dr.  Coley  reports  168  cases, 
19  of  which  have  remained  well  from  3-22  years;  he  also  reports 
36  cases  successfully  treated  with  the  toxins  by  other  men,  30 
of  which  have  remained  well  from  1-17  years. 

As  regards  Dr.  Coley's  final  results  up  to  191 7,  a  brief  report 

1 "  Melanotic  Cancer,"  Trans.  Amer.  Surg.  Ass'n.,  1916. 
2 End  results    following  total  excision.     Clin.  Surg.    Assoc,  1920;    Annals 
of  Surgery,  Aug.,  1920. 
zTrans.  of  the  Amer.  Surg.  Ass'n.,  1915. 


BIO-THERAPY  OF  CANCER  277 

of  the  same  may  be  found  in  an  astract  of  remarks  made  at  a 
discussion  of  the  Treatment  of  Inoperable  Sarcoma,  before 
the  New  York  Academy  of  Medicine,  April  19,  191 7,  covering 
1,000  cases  of  all  types  of  sarcoma,  and  showing  that  in  95,  or 
almost  ten  per  cent  the  tumors  disappeared  as  the  result  of  treat- 
ment. Of  these,  8  remained  well  and  free  from  recurrence  three 
to  five  years;  34  from  five  to  ten  years;  14  from  ten  to  fifteen 
years,  7  from  fifteen  to  twenty  years;  5  from  twenty  to  twenty- 
four  years;  in  other  words,  68  cases  remained  well  from  three 
to  twenty-four  years.  In  five  of  these  cases  radium  and  x-ray 
were  used  in  addition  to  the  toxins.  The  diagnosis  was  confirmed 
by  microscopical  examination  in  all  but  10  cases.  Dr.  Coley's 
Brussels'  paper,  19 13,  contains  a  tabulated  report  of  124  cases 
of  inoperable  sarcoma  successfully  treated  by  other  surgeons, 
in  no  of  which  the  patients  have  remained  well  from  one  to 
twenty  years,  and  87  from  three  to  twenty  years. 

In  vaccino-therapy,  as  carried  out  by  Coca,1  regression  was 
frequently  seen,  but  more  commonly  in  the  febrile  cases.  The 
fact  that  puncture  of  the  thermic  center  in  canine  tumor  has 
been  followed  by  regression  appears  to  show  that  fever  has 
much  to  do  with  regression.  According  to  Ewing  heat  is 
without  influence  on  growing  cancer  cells,  but  since  the  date  of 
the  paper,  raising  the  temperature  of  the  medium  to  a  certain 
degree  has  been  found  to  inhibit  the  growth  of  mouse  tumors. 
If  heat  is  the  principle  involved  in  these  regressions,  then  we 
should  speak  of  thermo-therapy. 

Under  sero-therapy  in  the  strict  sense  of  the  word  Ewing 
first  mentions  the  use  of  convalescent  serum.  At  first  it  was 
thought  that  in  cures  thus  produced  specific  immune  bodies 
were  active,  but  it  was  later  ascertained  that  injections  of 
various  organ  extracts  gave  the  same  results.  Edel  reduced 
the  size  of  cancers  by  injecting  human  placental  blood.  The 
same  results  were  obtained  with  normal  blood  serum  by  Arloing 
and  Courmont,  injected  in  a  manner  not  stated.  It  was 
thought  that  the  only  factor  amenable  to  treatment  was  the 

xCoca,  Zettschr.  f.  Immunital.  forsch.,  1911-2,  xiii,  p.  524. 


278  CANCER 

secondary  inflammation  about  the  tumors.  In  non-specific, 
or,  as  they  may  be  termed,  normal  sera,  used  by  numerous 
reporters,  the  mechanism  was  explained  by  Vidal  in  several 
ways,  as  follows:  (1)  The  action  of  the  toxic  component  already 
mentioned,  which  also  can  cause  the  fever,  is  called  autolytic, 
acting  on  the  necrotic  center;  (2)  the  enzyme  component  may 
have  a  hostile  action  against  the  cancer  cell  (as  shown  in  tryp- 
sin); (3)  an  antibody  component,  the  existence  of  which  is 
doubtful  or  rather  its  action  is  non-specific;  and  finally  (4) 
The  thermic  action  which  has  been  attributed  to  the  toxic 
component. 

The  author  now  passes  to  the  autotherapy  of  cancer  and  to 
the  treatment  based  thereon,  namely,  that  of  injecting  exudates 
of  cancer  subjects  into  cancerous  patients.  The  first  clinical 
fact  quoted  was  the  spontaneous  cure  of  mammary  cancer 
after  absorption  of  pleural  exudates.  The  observer  was 
Mackay,  1907,  and  the  cancer  was  in  the  most  advanced  state — 
cancer  en  cuirasse. 

This  pointed  apparently  to  the  existence  of  histolytic  sub- 
stances in  the  exudate.  But  in  a  considerable  series  of  spon- 
taneous cures  on  record  there  was  not  one  in  which  an  exudate 
had  been  absorbed.  Hodenpyl  then  took  advantage  of  the 
numerous  cases  of  cancerous  ascites  to  experiment  on  animals. 
In  one  case  a  very  extensive  recurrent  and  metastatic  breast 
cancer,  including  cancer  of  the  liver,  in  which  chylous  ascites 
was  present,  the  disease,  severe  and  generalized  as  it  was, 
appeared  to  be  undergoing  spontaneous  cure.  The  ascitic 
fluid  in  this  case  was  used  in  the  treatment  of  40  cases  of  in- 
operable cancer,  and  in  some  of  these  the  initial  improvement 
was  remarkable  but  was  not  maintained,  while  the  donor  of 
the  exudate  herself  succumbed,  not  to  the  disease  but  because 
the  liver  had  become  completely  atrophic  as  the  result  of  cancer- 
ous infiltration.  Ewing  examined  slides  from  the  liver  and  the 
evidence  of  regression  of  the  cancer  process  was  complete. 
Of  the  40  patients  treated  with  this  fluid  all  died  but  one,  in 
whom  the  inoperable  case  became  operable  and  was  apparently 


BIO-THERAPY  OF  CANCER  279 

cured  by  removal.  Dr.  Ill  of  Newark  then  encountered  a  case 
almost  the  duplicate  of  the  first,  in  which  death  seems  to  have 
been  due  to  the  excessive  accumulation  of  ascitic  fluid.  The 
liver  was  much  as  in  the  first  case  just  mentioned.  Shaffer 
examined  both  sera  but  could  find  no  active  principles  either 
by  chemical  or  bio-logical  tests.  Rushmore  of  Boston  had  a 
third  case  of  this  type,  and  the  general  conclusion  was  that 
this  serum  for  some  unknown  reason  can  like  many  others  cause 
some  regression  in  cancer  growths.  To  these  three  cases  and 
the  Mackay  case  of  cure  with  pleuritic  exudate,  may  be  added 
a  fifth  by  Turner  which  recalls  Mackay's.  There  was  cancer 
en  cuirasse  with  pleuritic  effusion,  and  the  patient  received 
injections  of  her  own  serum  plus  others  of  nucleinate  of  soda, 
a  fever-producing  substance.  The  patient  was  kept  at  a 
febrile-temperature  for  3  months  and  was  completely  cured. 
In  the  other  four  cases  fever  was  not  a  factor,  nor  was  there  any 
evidence  of  toxic  activity. 

The  line  of  research  passed  on  to  the  alleged  discovery  by 
Freund  and  Kaminer,  that  while  normal  serum  dissolves  cancer 
cells  the  serum  of  cancerous  patients  has  lost  this  property. 
The  reactions  were  practically  100  per  cent  positive,  and  hence, 
this  test  has  sometimes  been  used  in  diagnosis.  Normal  serum 
is  thus  seen  to  contain  a  cytolytic  substance  which  can  be  visual- 
ized by  numerous  properties.  It  does  not  go  through  a  dialyser, 
is  thermolabile,  etc.,  and  may  be  adherent  to  the  lecithin  of  the 
serum.  The  inhibiting  agent  in  the  cancer  serum  is  contained 
in  the  euglobulin.  The  remarkable  significance  of  this  dis- 
covery is  vitiated  by  the  fact  that  others  who  followed  the 
Freund-Kaminer  technique  have  obtained  very  different  re- 
sults. Ewing  found  that  the  emulsions  made  according  to 
the  originators  were  not  sterile  and  could  not  be  sterilized. 
Simon  and  Thomas  obtained  results  which  completely  over- 
turned those  of  Freund  and  Kaminer,  while  each  investigator 
found  some  added  discrepancy,  and  the  whole  superstructure 
had  to  be  given  up.  No  doubt  the  basic  facts  were  those  of 
autolysis. 


280  CANCER 

Vidal  sought  to  prepare  a  cytolytic  cancer  serum  based  on 
the  principles  involved  in  complement  deviation  for  diagnosis. 
He  studied  many  tumor  and  tissue  emulsions  for  the  presence  of 
antigens,  also  making  combinations.  He  prepared  specific 
antisera  from  the  antigens  by  dog  experiments,  and  added  these 
to  the  antigens.  The  resulting  serum  had  the  usual  effect  of 
temporary  regression.  Of  ioo  patients  treated  no  improve- 
ment was  noted  in  50,  while  among  the  others  were  some 
permanent  cures  (three).  A  number  of  cases  were  so  much 
benefited  as  to  become  operable.  Of  the  actual  cures  were  a 
cancer  of  the  breast  and  one  of  the  rectum.  While  accepting 
Vidal's  facts  Ewing  is  doubtful  concerning  the  explanation. 
Vidal  regards  the  principle  involved  as  the  activity  of  an  anti- 
amboceptor.  Ewing  thinks  the  principle  less  involved  and  not 
differing  from  that  of  a  toxic  serum. 

The  next  line  of  study  is  that  of  vaccination  with  cancer 
emulsions.  Thus  far  but  few  have  reported  benefit.  Coca  and 
Oilman  got  a  surprising  result  in  Manila,  but  ever  afterward  the 
best  that  could  be  gotten  was  marked  regression.  In  1910 
Bertrand  showed  an  almost  cured  advanced  breast  case,  in 
which  he  had  vaccinated  the  subject  with  dried  breast  cancer 
tissue — that  is,  he  had  injected  emulsions  of  the  same.  Other 
surprising  results  were  seen  only  in  sarcomata.  The  treatment 
is  not  free  from  danger. 

The  remarkable  cures  narrated,  few  though  they  are,  seem  to 
show  that  sero-therapy  may  play  a  role  in  cancer  therapy.  Not 
all  could  have  been  coincidental,  spontaneous  cure,  or  if  such  be 
the  case,  then  the  mechanism  employed  by  Nature  was  of  the 
sero-therapeutic  type.  Side  by  side  are  many,  scores,  of 
partial  regressions.  The  case  material  used  in  these  instances 
is  always  of  the  worst  character,  for  one  cannot  experiment  on 
patients  with  good  operative  prognosis.  The  chronic  cancer 
invalid  is  of  course  quite  another  subject  than  the  robust  and 
well-nourished  one  who  is  just  developing  the  disease.  There 
is  so  little  to  work  on  in  these  desperate  cases — so  little  to  be 
done  by  the  reparative  forces  of  the  body — that  such  cures 


BIO-THERAPY  OF  CANCER  281 

should  command  our  admiration.  The  cure  of  these  cases, 
as  Turner  states,  is  paradoxical,  for  we  know  nothing  about 
cancer  immunity.  The  most  promising  lead  to  follow  is  that 
of  slow,  passive  immunization  by  injecting  the  products  of 
tumors.  This  is  more  than  suggested  by  the  cures  in  exudate 
patients,  for,  despite  laboratory  reports,  the  exudates  should 
contain  something  which  inhibits  cancer  development.  Ewing 
is  sure  that  the  blood  of  the  cancer  subject  contains  some 
neutralizing  anti-body  which  can  also  pass  into  other  fluids 
such  as  exudates. 

This  quasi-specific  activity  differs  from  the  favorable  action 
of  many  non-specific  fluids.  It  is  quite  possible  to  produce  a 
histolytic  substance  so  specific  in  character  that  it  will  simply 
melt  away  the  cancer  cells,  even  despite  the  cachectic  state  of 
the  subject.  This  is  evident  from  the  study  of  the  most  striking 
cases  quoted.  The  tumor  itself  is  where  we  much  look  for  the 
cure  of  the  tumor.  With  this  in  view  many  studies  of  cancer 
products  have  been  made  without  regard  to  the  clinical  aspect. 
Among  these  are  glycogen,  ferments,  etc.  This  line  of  work  has 
accomplished  little.  Cancer  nucleo-proteids  may  offer  the  best 
outlook.  Instead  of  tumor-tissue  that  of  very  young  embryos 
has  been  used,  after  having  undergone  autolysis.  It  has  been 
inferred  that  embryonal  and  growing  tumor-tissues  have  much 
in  common.  Fischera  has  announced  cures  no  better  nor  worse 
than  those  obtained  from  various  sera.  The  principle  is  prob- 
ably the  same.  The  action  of  autolysis  must  set  free  certain 
toxins,  so  that  any  specific  property  which  originally  resided  in 
the  fresh  cancer  or  embryonal  cell  must  lose  any  specificity  of 
action  under  continuous  self  digestion. 

Reviewing  the  entire  subject  the  chief  drawback  is  the 
absence  of  selection  of  cases.  All  cancer  looks  the  same  to  the 
surgeon,  but  to  the  pathologist  they  present  much  individuality, 
and  on  the  latter  basis  it  may  be  possible  to  decide  when  to  use 
a  serum,  when  a  toxin,  and  when  a  vaccine,  etc.  The  means  for 
making  this  selection  are  not  stated  but  depend  on  many  factors, 
such  for  example  as  the  state  of  the  endocrine  organs.     Blood 


282  CANCER 

examinations  might  furnish  a  clue,  as  well  as  the  presence  or 
absence  of  a  local  or  general  reaction  to  a  provocative  injection. 
Failing  in  getting  a  criterion  for  selection,  the  next  best  course 
would  be  the  combination  of  a  number  of  resources,  such  as  the 
use  of  thyroid  or  pluri-glandular  extracts,  polyvalent  serum,  or 
vaccine,  etc.  When  the  regressive  action  of  one  product  has  run 
out  another  might  be  substituted.  Ewing  is  silent  on  the  com- 
bination of  seric  factors  with  radium  and  #-rays.  It  would 
seem  that  in  the  combined  methods  which  are  now  being  en- 
dorsed some  serum  treatment  might  be  added. 

Berkeley's  Serum. — After  the  publication  of  Ewing's  paper  in 
191 2  the  serum  prepared  by  Berkeley  at  Cornell,  with  the  help 
of  Beebe,  attracted  considerable  attention.  Berkeley  wrote 
several  papers  and  the  one  we  abstract  appeared  when  the 
author  had  been  working  on  it  3  years.1  The  quest  of  the 
investigators  was  to  find  a  remedy  soluble  in  the  blood  and 
lymph  and  capable  thereby  of  transportation  to  all  portions 
of  the  organism,  which  could  prevent  or  antagonize  the  for- 
mation of  metastases.  His  inspiration  came  from  von  Dungern, 
Vidal,  and  Hodenpyl.  The  possibility  of  reaching  cancer 
through  an  antiserum  is  said  to  have  originated  with  the  first 
named.  Credit  is  given  Beebe  for  his  early  work  on  anti- 
thyroid serum.  The  good  work  of  Hodenpyl  was  interrupted 
by  his  death  in  19 10. 

The  author  claims  successes  in  a  field  marked  by  failures. 
He  attributes  success  to  great  pains  taken  with  antigens  and 
with  details  in  general.  The  present  paper  deals  with  clinical 
results  and  naturally  with  less  than  3  years  experience,  per- 
manent ones  cannot  be  supplied.  He  received  from  surgeons 
and  others  135  to  140  cases  of  tumor,  from  which  25  could  be 
eliminated  as  doubtful  or  benign.  The  others  were  used  in 
making  stock  and  serum  and  for  treatment.  Of  104  cases  15 
were  so  far  gone  that  no  treatment  was  undertaken.  Of  post- 
operative recurrences  microscopic  slides  were  obtained  to  make 
sure  of  histological  malignancy.     Since  all  forms  of  malignant 

1  Berkeley,  Medical  Record,  April  25,  1914. 


BIO-THERAPY  OF  CANCER  283 

tumor  are  said  to  have  been  represented,  the  paper  as  a  whole 
cannot  refer  to  cancer  alone,  but  many  inoperable  and  recurrent 
cancers  were  mentioned.  The  serum  proper  is  not  discussed, 
except  as  above,  but  the  doses — 5  to  50  c.c. — were  injected 
intravenously  and  subcutaneously  at  intervals  of  a  few  days. 
A  member  of  the  New  York  Board  of  Health  improved  the 
serum  by  concentrating  it.  The  unmodified  serum  continued 
to  give  an  anaphylactic  shock  of  mild  type  (there  were  but 
two  cases  of  severe  shock)  together  with  blushing,  urticaria, 
fever,  etc.  The  work  of  the  author  seems  closely  related  to 
that  of  Vidal  as  quoted  by  Ewing;  as  he  uses  the  complement 
deviation  method. 

Some  of  the  cases  quoted  are  as  follows:  A  woman  with  cancer 
of  the  breast,  small  per  se  but  with  much  axillary  imvolvement, 
had  had  it  removed  by  Halsted  operation.  She  received  an  in- 
travenous injection  of  serum  without  the  slighest  reaction.  The 
operation  had  been  difficult  and  the  prognosis  could  hardly 
have  been  favorable,  but  she  was  surely  well  21  months  later, 
and  probably  still  later.  In  a  second  case  the  tumor  of  the 
breast  and  amount  of  tissue  removed  weighed  2  lb.  Three 
years  later  she  was  well  and  working  in  a  department  store. 
A  third  case  in  the  breast  was  much  like  the  preceding.  An 
operation  was  performed,  although  the  mass  was  ulcerated 
and  the  patient  cachectic.  Serum  treatment  was  followed  by  a 
gain  of  25  pounds,  and  2  years  later  she  was  well.  A  fourth  case 
was  cancer  of  the  sigmoid,  and  a  fifth  of  the  uterus,  involving 
the  bladder.  The  results  were  of  the  same  favorable  character. 
In  all  of  this  material  the  fact  of  an  antecedent  operation 
clouds  the  issue,  as  there  is  no  exact  proof  that  the  serum 
produced  the  given  result. 

It  is  not  known  that  Berkeley's  serum  has  any  subsequent 
history.  Beebe  who  sponsored  it  had  announced  1  year  later 
a  new  method  of  treatment  by  "autolysin. "  This  preparation 
has  nothing  to  do  with  the  autolytic  products  of  cancer  degen- 
eration, but  is  a  saline  aqueous  extract  of  12  different  vegetable 
substances. 


284  CANCER 

Autolysin. — The  idea  of  this  treatment,  introduced  by 
Beebe,1  which  he  termed  "  autolysin ,"  originated  in  the  claimed 
success  of  a  poultice  composed  of  twelve  vegetable  ingredients, 
including  viola  tricolor,  colocynth,  quassia,  rhubarb,  etc.,  used 
on  ulcerated  cancers,  which  was  first  employed  by  Horowitz 
of  Budapest.  Extracts  were  made  by  Beebe  from  the  dry 
poultice  powder  and  injected  hypodermically.  The  use  of  the 
word  "autolysin"  indicates  that  the  action  on  the  cancer 
cells  is  that  of  a  lysin.  It  is  not  a  serum  and  should  not  be 
termed  such.  The  extract  contains  vegetable  protein,  salts 
and  extractives,  chlorophyll,  chromophyll,  and  lipoids,  and  is 
injected  into  the  arm.  From  15  to  90  minims  were  injected 
and  the  act  was  painful.  There  should  be  a  marked  local 
reaction  which  may  be  extreme,  and  reaches  its  maximum  in 
7  to  10  hours.  No  typical  general  reaction  follows,  although  one 
is  occasionally  seen,  with  fever.  Such  patients  are  sensitive  to 
vegetable  protein,  as  shown  by  the  coexistence  of  hay  fever. 
The  second  injection  may  cause  anaphylactic  reaction,  if  intra- 
venous. There  is  no  doubt  that  with  large  enough  doses  the 
first  injection  would  always  lead  to  a  severe  reaction,  compar- 
able to  acute  malaria,  but  the  dose  is  regulated  to  prevent  this. 
In  second  injections  anaphylaxis  is  immediate  and  may  be 
severe.  It  can  be  avoided  by  using  the  hypodermic  method 
instead  of  the  intravenous.  Or  it  may  be  disposed  of  by  adapta- 
tion to  the  point  of  tolerance. 

At  a  later  date  than  Beebe's  paper,  H.  S.  Williams2  made 
a  more  complete  study,  using  the  same  name,  autolysin,  for 
the  injection,  which  Beebe  had  used,  and  presumably  about  the 
same  in  composition.  In  all,  about  1,000  cases  are  said  to 
have  been  treated  throughout  the  country.  One  series  of 
nearly  500  is  analyzed,  and  50,  or  about  10  per  cent,  are  termed 
clinical  cures,  despite  the  shortness  of  the  interval.  But  the 
cases  were  all  hopelessly  inoperable,  whether  recurrences  after 

1  Beebe,  New  York  Medical  Journal,  May  15,  1915.  (This  was  followed  by 
several  others,  by  different  writers,  in  the  issue  of  October  9th.) 

2  Williams,  New  York  Medical  Journal,  November  13,  1915. 


BIO-THERAPY  OF  CANCER  285 

operation  or  unoperated  cases.  There  was  a  marked  aggregate 
extension  of  life,  while  pain  and  odor  were  favorably  influenced. 
In  regard  to  radium  and  x-rays,  these  resources  had  been 
exhausted  in  a  number  of  the  patients  before  coming  under 
treatment. 

The  number  of  physicians  to  test  the  method  has  been 
reckoned  as  138.  This  number  may  or  may  not  include  the 
local  men  who  carried  out  the  treatment  under  Dr.  Beebe,  for 
it  is  said  that  these  138  men  treated  but  272  patients  while 
Beebe  and  staff  alone  treated  nearly  500.  The  two  series  added 
together  give  a  material  of  between  700  and  800,  and  even  this 
does  not  account  for  the  grand  total  of  1,000  cases  mentioned 
earlier.  The  deficit  is  probably  found  in  the  200  cases  of  very 
recent  reports,  separately  considered  toward  the  close  of  the 
paper.  The  total  number  of  physicians  to  treat  cases  is  given 
as  200.  In  the  final  summary  by  Williams  we  note  the  follow- 
ing: effects  of  the  injections  may  be  startlingly  apparent, 
even  the  first  being  followed  by  softening,  which  should  not 
be  too  rapid  lest  the  growth  break  down  entirely.  Although 
there  may  be  much  swelling  and  induration  at  the  site  of  the 
puncture  no  abscess  is  known  to  have  formed.  A  reaction 
may  occur  and  should  be  expected,  and  failure  of  one  to  develop 
may  be  followed  by  an  intravenous  injection.  This  is  the 
reverse  of  what  is  given  in  Beebe's  paper,  in  which  there  is  a 
passage  which  seems  to  show  that  a  general  reaction  seldom 
occurs.  Too  rapid  breaking  down  has  advantages  and  dis- 
advantages. Some  of  the  best  results  have  followed  rapid 
breakdown  but  on  the  other  hand  hemorrhage  may  (rarely) 
develop.  Most  of  these  patients  had  become  morphine  addicts, 
and  it  becomes  possible  and  advisable  to  wean  them.  The 
softening  may  be  such  that  it  is  advisable  to  scoop  out  the 
softened  area. 

For  a  while  there  was  a  notable  silence  in  literature  as  to 
sero-therapeutic  remedies  for  cancer.  Whether  this  was  due, 
as  is  probable,  to  the  great  diffusion  of  radiation  endeavors,  or 
to    the   relatively  unsatisfactory  character  of  bio-therapeutic 


286  CANCER 

measures,  or  to  both  causes  acting  in  common,  or  to  some 
factor  which  is  not  yet  visible,  at  any  rate  it  seems  true  that 
efforts  in  this  direction  have  rapidly  abated.  Fischera1  writes 
of  the  biological  treatment  of  cancer,  his  article  having  been 
composed  in  191 7  and  may  be  contrasted  with  the  review  by 
Ewing  published  in  191 2.  Fischera  is  himself  the  originator  of 
the  use  of  autolysates  of  tumors  and  miscellaneous  tissues 
including  embryonal,  and  while  he  seems  to  retain  his  enthusi- 
asm for  his  own  methods  he  seeks  to  discredit  all  that  had  been 
previously  done  in  the  field  of  biological  treatment.  His  own 
he  calls  " histogenetic  chemotherapy."  He  gives  an  admirable 
account  of  the  history  of  biological  methods,  grouping  them 
into  antiparasitic,  passive  immunization  or  sero-therapy  in  the 
narrow  sense,  and  active  immunization  or  vaccino-therapy. 
The  antiparasitic  group  of  methods  was  entirely  based  on  the 
theory  that  cancer  was  due  to  various  fungi,  moulds,  bacteria, 
etc.,  so  that  the  treatment  is  strictly  causal.  This  is  not 
generally  remembered.  Bra,  who  seems  to  have  been  the 
first,  really  believed  that  a  myxomycetes  found  on  certain 
plants  was  the  cause  of  cancer.  He  used  killed  cultures, 
filtered,  and  was  followed  by  others.  As  usually  happens  early 
reports  were  good.  As  injections  caused  fever,  Ewing  would 
class  it  under  toxin  therapy.  Adverse  reports  caused  Bra  to 
seek  the  same  fungus  in  human  association,  but  his  new  product 
has  been  forgotten  for  years. 

It  is  otherwise  with  Schmidt's  cancroidin  which  is  still  used 
by  the  discoverer  and  others,  although  officially  condemned 
by  Orth,  the  successor  to  Virchow.  This  preparation  of 
cultures  of  the  mucor  racemosus,  the  latter  being  alleged  as  the 
cause  of  cancer,  has  been  in  use  for  years,  and  is  the  only  one  to 
survive.  The  persistence  of  the  author  has  led  some  of  the 
best  men  to  try  it,  including  Czerny,  who  associated  it  with 
radium  to  no  purpose. 

The  blastomycetes  was  accused  as  a  cause  by  Wlaeff  and 
San  Felice,  and  the  preparation  made  therefrom  was  given  a 

1  Fischera,  Journal  of  Cancer  Research,  1918,  III,  303. 


BIO-THERAPY  OF  CANCER  287 

good  tryout,  but  the  idea  is  completely  extinct.  Doyen 
believed  (or  pretended  to)  that  the  cancer  was  due  to  the 
micrococcus  neoformans.  The  remedy  produced  from  the  latter 
was  tried  out  by  leading  French  surgeons  and  condemned,  and 
along  with  Doyen's  theory  has  been  laid  on  the  shelf. 

The  apparent  successes  produced  by  all  of  these  methods 
have  been  explained  away  by  wrong  diagnoses,  coincidence, 
psychic  influence,  better  local  and  general  hygiene,  and  so  on. 
Fischera  does  not  take  this  view,  and  Ewing  who  mentions 
some  of  these  factors  has  isolated  some  cases  which  pass  the 
tests. 

Attempts  to  cure  cancer  by  passive  immunization  are  summed 
up  in  the  work  of  Vidal,  who  seems  to  have  covered  all  the 
possibilities  of  the  method.  His  work  is  described  by  Ewing. 
Fischera  adds  that  sero-therapy  has  not  fulfilled  expectations 
and  has  now  lost  most  of  its  experimental  basis.  Besides, 
Jensen  was  forced  to  admit  that  regressions  under  sero-therapy 
could  be  explained  sufficiently  by  spontaneous  motivation. 
Sera  are  not  only  non-specific  but  have  no  proved  efficacy. 

Active  immunization  or  vaccino-therapy  is  dangerous,  and  it 
is  possible  by  such  means  to  cause  implantation — evidently  in 
animals  only — but  this  prevents  a  proper  study  of  it.  Delbet 
obtained  one  positive  result  by  taking  a  freshly  amputated 
cancer  and  reducing  it  to  pulp,  which  was  injected  under  the 
skin  in  three  or  four  places.  There  was  no  relapse,  but  as  he 
also  used  radiation  the  case  cannot  be  regarded  as  conclusive. 

Aside  from  a  possibility  of  implantation  the  method  is 
dangerous  on  general  principles,  as  is  stated  in  E wing's  review. 

Fischera  is  still  at  work  developing  his  own  method  and 
making  new  discoveries.  There  are  no  clinical  cases  in  his 
article.  He  is  using  autolysates,  and  filtrates,  and  ordinary 
tissues,  presumably  mostly  in  the  embryonal  state.  Many  of 
his  laboratory  colleagues  are  at  work  along  the  same  lines. 
He  has  shown  that  certain  organs  have  a  greater  selective 
action  than  others  in  the  lysis  of  tumors  and  in  provoking  a 
hyperplastic  reaction.     Emulsions  of  liver  and  spleen  appear 


288  CANCER 

to  be  superior  to  others.  He  has  discovered  that  large  doses 
have  an  opposite  action  to  small  ones,  and  may  cause  the 
tumors  to  proliferate.  This  same  behavior  is  seen  with  radium 
and  x-rays,  save  that  here  it  is  the  small  dose  which  is 
dangerous. 

Another  important  discovery  is  that  the  amount  given  must 
be  in  direct  proportion  to  the  amount  of  tumor  mass.  In 
other  words  the  action  is  purely  quantitative  and  not  due  to 
enzymes,  etc.  Koch  says  the  same  of  his  tissue  thrombin,  in 
the  use  of  which  he  has  reported  such  marvellous  results  in  the 
Medical  Record,  November  3,  1920.  Until  these  latter  are 
confirmed  by  others,  or  demonstrated  in  a  good  hospital  under 
competent  medical  supervision,  they  must  be  taken  with 
caution  and  the  whole  conception  and  practice  has  been  thor- 
oughly investigated  and  condemned. 

Dr.  H.  S.  Williams,  of  New  York,  has  continued  his  work  on 
the  relation  of  protein  derangement  and  its  correction  in  cancer 
and  many  other  diseased  conditions  of  older  years,  and  has 
recently  presented  it  very  thoroughly  and  in  a  manner  which 
commands  attention  and  merits  confidence.  The  subject 
under  the  title  of  "The  Proteomorphic  Theory"  is  developed 
in  a  large  book1  and  in  subsequent  journal  articles2'3,  so  defi- 
nitely as  to  warrant  serious  consideration  and  some  little  space. 
These  represent  in  a  large  measure  the  ideas  promulgated  some 
years  ago,4  but  with  a  greatly  extended  experience  and  profound 
study,  as  will  presently  be  seen. 

The  correctness  of  the  theory  on  which  it  is  based,  is  demon- 
strated by  accurately  recorded  blood  counts  in  hundreds  of 
cases,  taken  before  and  after  sufficient  proteal  treatment  had 
been  given.  These  latter  show  by  many  tables,  clearly  and 
remarkably  the  changes  toward  normality  developed  in  the 
blood  in  a  very  large  share  of  cases,  accompanying  the  progress- 

1  Williams,  "The  Proteomorphic  Theory,  etc."     New  York,  1918. 

2  Williams,  The  Medical  Record,  November  22,  1919. 
5  Williams,  The  Medical  Record,  December  20,  1919. 

4  Williams,  New  York  Medical  Journal,  October  2,  1914,  American  Medicine, 
October  and  November,  1914. 


BIO-THERAPY  OF  CANCER  289 

ive  improvement  in  the  patient  and  of  the  disease,  so  that  this 
line  of  thought  is  certainly  one  which  should  be  generally 
accepted  if  true.  The  plan  of  treatment  based  thereon  has 
also  been  widely  tested  in  certain  public  institutions  and  by 
hundreds  of  physicians  all  over  the  country,  to  whom  the 
material  has  been  furnished,  and  the  confirmatory  reports 
fully  bear  out  the  statements  of  Dr.  Williams.  While  the 
substance  has  thus  far  been  prepared  in  and  sent  out  from  his 
laboratory,  there  is  no  secrecy  in  the  matter,  and  the  formula 
by  which  it  is  prepared  is  published,  and  will  shortly  be  here 
given,  so  that  it  can  be  made  in  laboratories  of  Boards  of 
Health  and  public  institutions,  but  it  has  never  been 
commercialized. 

The  basis  of  the  proteomorphic  theory  and  treatment  of 
cancer  rests  on  the  now  recognized  metabolic  or  constitutional 
nature  of  the  disease,  as  opposed  to  its  purely  local  character, 
and  the  treatment  is  founded  on  the  action  of  the  blood  cells, 
as  altered  by  the  parenteral  administration  of  foreign  vegetable 
proteins,  to  which  is  given  the  name  of  Proteals. 

In  order  to  really  understand  the  plan  and  scope  of  this 
treatment  some  knowledge  should  be  had  of  the  basic  facts 
upon  which  it  rests,  which  are  very  fully  presented  in  Dr. 
Williams'  articles  and  in  his  book  of  over  300  pages.  This 
latter  in  some  parts  is  pretty  hard  reading,  as  he  goes  so 
minutely  into  scientific  statements  in  regard  to  the  char- 
acter of  protein  and  its  dismemberment  and  synthesis  into  living 
tissue,  with  chemical  formulae.  This  grasp  of  the  subject  can 
perhaps  be  best  obtained  by  utilizing  freely  some  of  the  material 
which  he  gives. 

1.  Certain  substances  administered  hypodermically  have 
been  observed  to  have  a  definite  influence  on  the  clinical 
progress  of  persons  suffering  from  inoperable  cancer  of  many 
types.  These  substances  include  extracts  of  plant  products 
and  animal  products  of  many  kinds:  but  they  have  this  point 
in  common — all  of  them  contain  protein  or  the  products  of 
partial  protein  hydrolysis. 

19 


290  CANCER 

2.  The  observed  modification  in  cancer  subjects  through  ad- 
ministration of  these  substances  include:  Alleviation  of  pain, 
modification  of  discharge,  modification  of  the  tumor  itself,  and 
modification  in  the  general  health  and  mental  attitude  of  the 
patient. 

3.  The  same  protein  substances,  administered  hypodermic- 
ally,  have  been  observed  to  benefit  markedly  cases  exhibiting 
various  kinds  of  metabolic  disturbances. 

4.  The  clinical  betterment  of  these  cases  has  been  observed 
to  be  associated  with  blood  modifications  of  a  definite  and  pre- 
dictable character,  namely:  increase  of  hemoglobin,  increase  of 
number  of  red  corpuscles,  increase  of  large  mononuclear  leuco- 
cytes, increase  of  eosinophiles,  and  modification  of  numbers  of 
polynuclears  and  small  lymphocytes,  in  the  direction  of  the  nor- 
mal; also  with  conspicuous  qualitative  changes  in  the  direction 
of  the  normal. 

5.  Physiological  changes,  including  rises  of  temperature, 
quickened  pulse,  and  a  chill  are  not  infrequently  associated  with 
the  administration  of  some  of  the  remedies  in  question,  suggest- 
ing an  anaphylactic  reaction,  not  known  to  be  produced  by  any- 
thing but  protein  or  its  products.  This  reaction  appears  not 
to  be  evoked  in  the  same  degree  by  partially  hydrolyzed  proteins. 

6.  It  has  been  observed  that  a  condition  of  immunization 
appears  to  be  attained  sooner  or  later,  after  which  the  patient 
no  longer  responds  in  the  same  way  to  a  particular  protein;  but 
that  a  change  to  another  protein  may  bring  about  a  new  re- 
sponse, with  possibilities  of  cumulative  beneficial  effects. 

He  gives  then  certain  theories  on  which  he  explains  these 
observed  facts: 

1.  The  essential  point  of  contact  between  the  different  sub- 
stances administered  hypodermically  is  their  protein  content 
(either  the  full  molecule  or  products  of  partial  hydrolysis). 

2.  Any  foreign  protein  injected  into  the  parenteral  system 
serves  as  an  antigen,  and  stimulates  the  defensive  mechanism 
of  the  body  to  the  production  of  antibodies,  capable  of  hydrolyz- 
ing  foreign  proteins  of  various  types. 


BIO-THERAPY  OF  CANCER  291 

3.  Such  antibodies  are  enzymic  in  character,  and  both  specific 
and  general  in  nature — that  is  to  say,  they  hydrolyze  the  partic- 
ular protein  injected,  but  also  other  foreign  proteins  if  present. 

4.  The  proteins  of  cancer  are  in  a  sense  foreign  proteins,  and 
fall  within  the  scope  of  action  of  the  enzymes  called  forth  by 
the  medical  protein  antigens.  The  degenerative  diseases  of 
middle  life  and  old  age  are  usually  associated  with  disturbances 
of  metabolism,  involving  the  parenteral  invasion  of  foreign 
proteins,  or  the  undue  retention  or  incomplete  catabolism  of 
protein  end  products. 

5.  The  mechanism  particularly  involved  in  the  production 
of  the  protein-hydrolyzing  enzymes  is  the  blood-forming 
mechanism  and  its  products,  the  white  and  red  corpuscles, 

6.  The  general  province  of  the  white  corpuscles  is  to  deal  with 
the  full-sized  protein  molecule,  or  its  early  cleavage  products, 
and  the  province  of  the  red  corpuscles  is  to  deal  with  the  end 
products  of  polypeptid  order,  including  bodies  of  the  hypoxan- 
thin-xanthin-uric  acid-urea  series. 

7.  The  condition  of  the  abnormal  hyperplasia  of  the  cells 
of  various  organs  of  the  body,  including  the  blood-forming 
organs,  the  coats  of  the  arteries,  and  the  cells  of  epithelial,  endo- 
thelial, and  connective  tissues,  may  be  spoken  of  as  a  condition 
of  hyper-proteomorphism,  or  the  cancerous  condition.  All  such 
conditions  are  more  or  less  subject  to  clinical  and  physiological 
benefits  from  the  administration  of  protein  antigens — the  effect 
being  indirect  and  conditioned  on  changes  in  corpuscular  num- 
bers or  enzymic  activities. 

8.  Autolyzed  cancer  cells  themselves  serve  as  antigens,  stimu- 
lating the  blood-forming  mechanism,  but  ultimately,  in  unfavor- 
able cases,  leading  to  the  exhaustion  and  overpowering  of  this 
mechanism  through  over-stimulation,  and  to  the  excessive 
destruction  of  corpuscles. 

9.  Protein  antigens  as  a  whole  may  be  conveniently  spoken 
of  as  Proteantigens.  Considering  the  observed  action  of  these 
proteins  in  stimulating  the  increase  of  the  large  monocytes,  the 
word  Monocytosins  may  be  used  as  a  synonym,  or  a  more  gen- 


292  CANCER 

eral  and  perhaps  more  appropriate  work  would  be  Cytogens. 
He  adheres  to  the  word  Proteals  in  all  writings,  and  considers 
that  the  essence  of  the  Proteomorphic  theory  is  the  relative 
action  of  the  white  and  red  corpuscles  of  the  blood  just  mentioned ; 
namely,  that  the  mononuclear  leucocytes  are  the  agents  vitally 
concerned  in  beginning  hydrolysis,  and  that  the  red  cropuscles 
are  the  agents  concerned  with  the  completion  of  decompound- 
ing of  foreign  proteins  in  the  parenteral  system. 

Dr.  Williams  seems  to  have  departed  very  decidedly  from  the 
line  followed  by  Dr.  Beebe  in  the  composition  of  the  vegetable 
fluid  for  injections,  and  gives  very  freely  and  fully  his  experi- 
ence in  seeking  for  the  best  vegetable  protein  and  the  mode  of 
preparation  of  the  solution  used,  which  should  not  be  called  a 
serum,  as  no  animal  product  is  used.  He  gives  a  list  of  some 
five  substances  which  he  has  mainly  used  to  supply  the  vege- 
table protein:  alfalfa  meal,  mustard  seed,  millet  seed,  alfalfa 
seed  and  rape  seed,  each  with  a  number  to  designate  them  in 
his  laboratory,  and  then  five  mixtures  of  several  of  these  solu- 
tions, any  or  all  of  which  single  proteals  or  compound  mixtures 
he  may  use  singly  or  combined,  as  the  conditions  of  the  patient 
or  the  progress  of  the  case  may  indicate.  He  explains  that 
these  proteins  are  really  foreign  to  the  organism  as  foods,  and 
so  act  efficiently  in  disintegrating  others.  He  is  also  experiment- 
ing with  proteins  taken  from  nine  other  vegetarian  articles, 
edible,  such  as  oats,  potato,  wheat,  carrot,  etc.,  but  apparently 
has  not  yet  formulated  their  relative  value.  He  is  very  clear 
in  regard  to  the  necessity  of  changing  the  vegetable  protein 
employed  from  time  to  time  when  immunity  seems  to  be 
established  and  when  the  progress  of  the  case  does  not  seem 
satisfactory,  either  from  the  feelings  or  state  of  the  patient,  or 
the  condition  of  the  neoplasm.  This  is  only  quite  natural,  as  in 
the  treatment  of  any  disease  a  change  of  remedies  now  and 
then  may  be  essential  to  a  successful  issue. 

Space  does  not  permit  of  greater  elaboration  of  this  most 
interesting  and  important  subject,  and  for  full  details  the 
references  given  must  be  consulted.     We  may,  however,  say 


BIO-THERAPY  OF  CANCER  293 

that  for  cancer  he  turns  first  to  a  proteal  containing  alfalfa 
protein,  or  a  combination  of  those  from  alfalfa  and  millet. 
"Not  infrequently,"  says  he,  "I  shift  from  one  proteal  to  an- 
other, experimentally,  after  a  few  doses;  and  sometimes  I  find 
that  an  individual  patient  responds  far  better  to  one  type  of 
protein  than  to  another,  regardless  of  the  type  of  the  malady. " 

A  word  may  be  added  in  regard  to  the  preparation  of  proteals, 
quoting  Williams,  who  calls  attention  to  the  different  types  of 
protein  which  have  been  used.  The  one  (Beebe's  autolysin) 
contains  "the  unbroken  protein  molecule;  the  other  contains 
proteins  partially  hydrolyzed.  The  former  were  used  almost 
exclusively  until  late  in  1916."  Since  then  it  appears  that  he 
has  been  seeking  to  simplify  matters  and  to  select  the  particular 
vegetable  protein,  partially  digested  or  hydrolyzed,  suitable 
to  different  individuals  and  diseases. 

"The  essential  procedures  consist  of  the  extraction  of  the 
protein  from  the  ground  seed  or  other  vegetable  substance  by 
boiling  the  powdered  plant  products  for  from  2  to  4  hours  in  a 
very  dilute  solution  of  hydrochloric  acid  (20  to  80  c.c.  of  a  10  per 
cent  hydrochloric  acid  in  a  liter  of  water,  with  50  to  100  gms.  of 
the  plant  powder):  filtering:  neutralizing  with  sodium  hydro- 
xide: refiltering:  standardizing  by  the  Kjeldahl  nitrogen  test, 
so  that  the  solution  when  used  contained  2  per  cent  of 
protein:  sealing  in  ampules,  and  sterilizing  for  3  days 
discontinuously.  If  properly  prepared  it  makes  a  perfectly 
transparent  fluid  varying  in  color  from  amber  to  claret  according 
to  the  specific  protein  content.  The  partially  hydrolyzed 
protein  (alkali  albumen,  proteose,  peptone)  does  not  coagulate 
on  heating  but  is  partly  precipitated  by  alcohol.  Nitric  acid 
precipitates  it  in  part,  the  precipitate  being  dissolved  on  boiling, 
to  reprecipitate  on  cooling  (the  familiar  test  for  proteoses)." 

"Proteals  thus  prepared  are  pleasant  to  administer,  and  as  a 
rule  produce  little  or  no  reaction,  and  in  ordinary  dosage  no 
conspicuous  systemic  reaction.  No  case  of  anaphylactic  shock 
from  their  use  has  been  observed  by  me,  or  reported,  although 
many  thousand  ampules  of  proteals  of  this  character  have  been 


294  CANCER 

sent  from  my  laboratory,  to  a  large  aggregate  number  of 
physicians  in  all  parts  of  the  western  hemisphere,  and  adminis- 
tered to  a  great  aggregate  number  of  patients  suffering  from 
disturbances  of  protein  metabolism." 

''The  proteals  hitherto  used  most  extensively,  as  supplied 
from  my  laboratory  to  several  hunderd  physicians  in  various 
parts  of  the  world,  are  chiefly  those  made  from  alfalfa  seed, 
alfalfa  meal,  mustard  seed,  rape  seed,  hemp  seed  and  millet 
seed." 

Dr.  Williams  is  very  modest,  both  in  propounding  his  new 
theories  of  immunization  and  protein  disassociation  and  synthe- 
sis, as  also  in  regard  to  the  therapeutic  results  obtained.  But 
all  of  his  studies  represent  such  vast  research  and  intelligent 
grasp  of  the  various  aspects  of  metabolism,  together  with  such 
an  immense  amount  of  microscopical  work  and  the  exposition 
of  tables  of  the  beneficial  changes  taking  place  in  the  blood 
elements,  that  credence  should  certainly  be  given  to  his  work 
and  to  this  additional  aid  in  overcoming  cancer.  He  very 
properly  shows  that  it  is  of  wide  application,  as  it  has  been 
employed  by  several  hundred  practising  physicians,  many  of 
whom  have  no  special  knowledge  of  the  disease,  many  of  whom 
have  reported  most  favorably  of  the  results  obtained,  and  that 
it  may  be  combined  with  other  methods  of  treatment. 

He  says,  "One  of  the  greatest  merits  of  the  proteal  treatment 
is  that  it  enables  isolated  physicians,  in  the  remotest  hamlets, 
to  do  something  tangible  and  definite  toward  ameliorating  the 
condition  of  the  cancer  patient  who  has  passed  beyond  the 
reach  of  the  surgeon. 

"Thanks  to  the  new  treatment  the  most  inexperienced  practi- 
tioner can  do  more  today  for  the  amelioration  of  the  condition 
of  a  late  stage,  inoperable  cancer  case,  than  could  hitherto  be 
accomplished  by  the  most  experienced  practitioner  in  the  best 
metropolitan  cancer  hospital."  Hitherto,  he  has  been  able 
to  supply  institutions,  and  individuals,  mainly  free,  from  his 
private  laboratory,  to  the  extent  of  many  thousand  average 
doses,  but  has  also  brought  the  proteals  and  the  methods  of 


BIO-THERAPY  OF  CANCER  295 

their  manufacture  and  administration  to  several  prominent 
pharmaceutical  houses,  and  to  many  Boards  of  Health,  in  hopes 
that  the  latter  will  prepare  and  circulate  them  as  they  do 
ordinary  vaccines,  diphtheritic  antitoxin,  etc. 

Organotherapy. — Although  strictly  speaking  this  hardly 
belongs  here,  with  bio-therapy  as  commonly  understood,  it  is 
really  only  another  expression  of  the  attempt  to  control  cancer 
by  internal  measures  in  place  of  the  knife,  etc.  Moreover, 
the  influence  exercised  by  the  endocrinous  glands  on  metab- 
olism and  nutrition,  and  the  more  or  less  benefit  from  their 
employment  in  certain  cases  of  cancer,  add  indubitable  proof 
to  the  correctness  of  the  views  regarding  the  constitutional 
relations  and  nature  of  the  disease,  as  unfolded  in  these  pages. 

All  are  aware  of  the  abundant  studies  and  literature  on  the 
action  and  influence  of  the  secretions  of  the  ductless  glands  on 
nutrition,  and  there  is,  of  course,  no  doubt  but  that  they  play 
an  important  part  in  coordinating  the  life  processes  of  the  body, 
and  that  disturbance  of  their  action  can  and  does  produce 
disease.  This  is  seen  in  goiter,  cretinism,  and  myxcedema, 
from  dysthyroidism,  Addison's  disease  from  adrenal  disorder, 
and  acromegaly  and  gigantism,  from  pituitary  derangement, 
etc.  Evidence  is  accumulating  that  irregularities  in  the  action 
of  these  glands  have  some  relation  to  the  disturbed  metabolic 
condition  which  eventuates  in  the  neoplasms  in  various  regions 
which  we  call  cancer,  but  just  how  this  occurs  is  one  of  the  prob- 
lems which  it  will  take  time  and  assiduous  attention  and  work 
to  determine.  One  of  the  best  proofs  of  the  importance  of  the 
endocrinous  system  of  glands  is  that  complete  extirpation  of 
both  adrenals  in  the  higher  animals  is  invariably  fatal,  and  the 
strange  muscular  and  nervous  symptoms  which  may  end  in 
death,   which  follow  the  removal  of  the  parathyroids,   etc. 

The  most  prominent  among  the  ductless  glands  of  which  we 
have  much  knowledge  in  regard  to  cancer,  is,  as  we  all  know,  the 
thyroid,  which  has  been  pretty  clearly  shown  to  have  consider- 
able influence  over  epithelial  structures,  as  is  mentioned  else- 
where in  this  writing.     Its  sometime  beneficial  influence  in 


296  CANCER 

cancer  is  now  well  known.  Definite  and  satisfactory  knowledge 
of  the  relation  of  other  endocrinous  glands,  or  their  employ- 
ment in  carcinoma  is  not  accessible,  though  there  have  been 
statements  along  this  line  which  must  be  taken  with  caution 
until  more  conclusively  proved. 

The  action  of  these  glands  on  the  system  is  believed  to  be 
through  the  operation  of  what  has  been  called  a  hormone,  a 
chemical  substance  formed  in  one  organ  or  part  of  the  body  and 
carried  in  the  blood  to  another  organ  or  part,  which  it  stimulates 
to  functional  activity  or  secretion.  The  secretions  of  some  or 
all  of  the  ductless  glands  are  regarded  as  hormones,  so  is  secre- 
tine,  so  is  carbon  dioxide  formed  in  muscle  during  contraction, 
which  incites  the  respiratory  center  to  increased  activicy. 
It  is  supposed  to  be  generated  in  all  the  cells  of  the  body  during 
catabolism  and  anabolism,  and  the  cancer  cell  is  no  exception; 
its  secretion  being  abnormal  is  thought  to  exert  an  adverse 
influence,  as  the  condition  of  the  blood  has  been  found  to  be 
improved  temporarily  after  the  surgical  removal  of  a  cancerous 
mass,  as  I  have  witnessed. 

All  are  familiar  with  the  many  preparations  made  from  the 
ductless  glands  of  animals  which  have  been  advocated  in  the 
treatment  of  cancer,  many  of  them  without  satisfactory  scien- 
tific basis.  There  have  also  been  combinations  of  them  pre- 
sented, and  it  is  possible  that  in  the  future  pluriglandular 
extracts  may  be  found  of  service  in  this  disease. 

The  various  glandular  preparations  have  generally  been 
administered  through  the  stomach,  but  some  of  the  extracts 
have  been  used  hypodermically,  like  the  sera,  antitoxins, 
autolysin,  the  proteals,  etc.  Space  does  not  allow  of  our 
elaborating  this  subject  further,  especially  as  I  am  not  pre- 
pared personally  to  advise  concerning  the  employment  of 
other  than  thyroid  preparations,  which  I  have  found  satisfac- 
tory given  by  the  mouth,  as  mentioned  elsewhere. 

In  all  claimed  results  from  organo-therapy  we  must,  as  in  con- 
nection with  some  of  the  other  bio-therapeutical  remedies 
mentioned  in  this  chapter,  take  into  consideration  the  psychical 


BIO-THERAPY  OF  CANCER  297 

element,  whereby  a  measure  of  improvement  in  the  patient's 
general  condition  may  be  produced  by  the  hope  engendered 
from  a  new  remedy.  But  when  the  microscope  shows  a  changed 
and  improved  blood  condition,  together  with  improvement  in 
the  local  lesion,  in  the  way  of  diminished  secretion  and  correction 
of  the  foul  odor,  and  especially  with  a  diminution  in  the  size 
of  the  neoplasm  and  healing,  the  total  syndrome  must  be  more 
than  a  coincidence  or  a  mental  delusion. 

In  looking  over  this  chapter  one  is  struck,  as  with  so  many 
other  chapters,  by  the  strong  evidence  cropping  out  everywhere 
in  regard  to  the  systemic  or  constitutional  nature  of  cancer, 
as  opposed  to  its  purely  local  character,  so  that  the  accumulat- 
ing confirmation  of  it  is  so  clear  that  "he  that  runs  may 
read." 

All  the  studies  and  experience  in  bio-therapy  are  based  on  an 
attempt  to  alter  the  vital  action  of  the  system  from  within,  and 
not  by  measures,  such  as  the  knife  or  radiation,  directly  applied 
to  the  local  product  of  the  cancerous  dyscrasia.  Many  of  the 
observers  remark  on  changes  in  the  bio-chemical  relation  of 
cancer  cells,  which  they  hope  to  alter,  and  to  the  removal  of 
those  already  accumulated  into  appreciable  lesions,  which  they 
hope  to  effect  through  blood  changes  produced  by  various  sera, 
vaccines,  etc.  But,  as  far  as  the  reading  of  hundreds  of  pages 
reveals,  few  if  any  of  them  have  gone  into  matters  with  a  care 
and  fullness  of  microscopical  evidence  which  are  conclusive, 
as  has  Williams.  As  previously  remarked,  his  line  of  reasoning, 
in  his  book  and  journal  articles,  from  known  and  recognized 
data  regarding  digestion  and  metabolism,  and  also  cyto-chemis- 
try,  cyto-genesis,  and  cyto-lysis,  when  confirmed  as  it  has  been 
by  his  own  experience  in  very  many  cases,  as  well  as  in  that  of 
many  others,  seems  so  conclusive  that  the  principles  enunciated 
cannot  be  ignored.  Personally,  I  have  as  yet  had  experience 
in  the  employment  of  proteals  in  but  few  cases,  and  those  were 
not  treated  systematically  enough  to  report  upon,  but  I  am  now 
employing  it  and  shall  certainly  test  this  treatment  in  future,  as 


298  CANCER 

an  adjuvant,  inasmuch  as  in  principle  it  is  closely  allied  to  that 
indicated  in  these  pages. 

Finally,  as  hinted  by  one  writer  quoted  in  the  last  chapter, 
that  on  .r-rays  and  radium,  the  student,  observer,  or  specialist  in 
malignant  disease  should  not  be  tied  to  any  one  exact  plan  of 
treatment,  but  as  with  other  diseases,  he  should  know  the  entire 
subject  so  well  and  be  so  intelligent  and  broad  minded  that  he 
will  adopt  with  care  any  and  every  well  authenticated  means  of 
curing  his  patient. 


CHAPTER  XVII 

DIETETIC,  HYGIENIC,  AND  MEDICAL  TREATMENT  OF 
CANCER.    PROPHYLAXIS 

It  is  not  a  little  remarkable  that  so  little  serious  attention 
has  heretofore  been  paid  to  the  medical  treatment  of  cancer  in 
standard  works  on  the  disease,  in  view  of  the  occasional  strong 
statements  and  reports  which  have  appeared  from  time  to  time 
in  current  literature  and  in  occasional  books,  dating  back  for 
many  years,  some  of  which  have  been  quoted  in  earlier  chapters. 
The  value  of  some  of  this,  of  course,  may  be  impaired  by 
imperfect  observation  and  erroneous  diagnosis,  but  there  have 
also  been  plenty  of  good  men,  who  knew  the  disease  well,  who 
have  reported  favorable  results,  and  even  the  complete  dis- 
appearance of  cancer,  under  dietetic  regimen  and  proper 
medical  treatment  alone,  without  operative  interference  of  any 
kind. 

But  even  the  recent  and  best  books  on  the  disease  have  not 
in  the  slightest  degree  alluded  to  the  subject,  and  a  large  share 
or  almost  all  of  my  patients,  I  think,  have  been  told  strongly 
by  medical  men  and  surgeons,  that  there  was  no  possible  hope 
in  anything  but  the  knife.  The  laity,  therefore,  have  become 
so  strongly  imbued  with  this  idea  that  it  is  often  difficult  for 
them  to  see  or  believe  anything  different.  For,  as  the  drown- 
ing man  catches  at  a  straw,  so  the  cancer  patient  hopes  against 
hope  that  an  operation  will  be  permanently  successful  in  this 
particular  case,  although  the  odds  are  so  immeasurably  against 
it.  Laboratory  studies  have  always  fostered  the  idea  that 
cancer  was  wholly  a  local  process,  and  have  supported  the 
surgeons  in  this  stand  and  in  the  necessity  of  operations.  This 
and  the  glamor  of  surgery,  and  its  wonderful  and  often  spectac- 

299 


300  CANCER 

ular  success  along  many  lines,  have  created  such  an  obcession 
in  everyone's  mind  that  they  believe  that  almost  everything 
can  be  accomplished  by  an  operation. 

As  I  have  before  remarked,  from  the  enormous  work  which 
has  been  done  on  cancer  with  the  microscope  and  the  test  tube, 
it  would  seem  sometimes  that  research  workers  and  others 
have  become  somewhat  myopic,  and  not  far  sighted  enough  to 
recognize  the  true  value  of  statistical  studies  and  careful  clinical 
observations.  And  the  medical  profession  and  the  laity  have 
had  their  minds  diverted  from  the  gross  errors  of  living  which 
have  crept  in  with  modern  life,  and  which  are  undoubtedly  at 
the  bottom  of  cancer  and  of  many  of  the  other  ills,  such  as 
kidney  disease,  heart  disease,  arteriosclerosis,  etc.,  which  cause 
the  death  of  so  large  a  number  of  those  of  middle  age. 

From  what  has  preceded,  in  other  chapters,  it  is  understood 
that  there  is  no  one  definite  or  demonstrable  state  of  the  system 
which  is  certainly  productive  of  cancer,  and  possibly  such  will 
never  be  discovered.  But  we  have  seen  abundantly  that  the 
cancerous  subject  is  profoundly  disturbed  in  regard  to  meta- 
bolism and  we  have  found  that  this  disturbance  is  occasioned 
by  the  wrong  action  of  some  of  the  organs  which  in  health 
supply  the  proper  nutrition  to  all  the  cells  of  the  body.  We 
all  know,  even  from  personal  experience,  what  a  disturbing 
element  wrong  diet  can  be  to  the  system,  and  what  ills,  acute 
and  chronic,  are  caused  thereby. 

We  see,  then,  that  to  understand  and  rightly  treat  the 
systemic  condition  belonging  to  cancer,  which  is  indeed  its 
basic  factor,  one  needs  to  take  a  very  broad  view  of  the  complex 
processes  which  pertain  to  metabolism  and  nutrition.  This  is 
indeed  a  very  different  proposition  from  the  very  simple 
surgical  view,  which  regards  the  tumor  as  a  local  matter,  of 
absolutely  unknown  origin,  which  needs  only  the  knife  to  end 
its  career.  Candid  and  thoughtful  men  must  recognize  that 
deranged,  disturbed,  perverted  nutrition  is  the  bottom  fact  of 
all  erroneous  growth,  whether  it  be  obesity,  rickets,  or  cancer. 

Coming  down,  then,  to  the  actual  and  practical  facts  relating 


MEDICAL  TREATMENT  301 

to  the  dietetic,  hygienic,  and  medicinal  treatment  of  cancer, 
we  readily  see  that  "the  real  cancer  problem"  relates  to  placing 
the  patient  in  such  a  normal  and  ideal  state  of  life  that  the 
function  of  nutrition  is  performed  in  an  exactly  proper  manner, 
as  nature  intended,  and  from  which  man  has  erred  through 
the  manifold  temptations  incident  to  an  artificial  existence. 

The  requisites  of  this  are  fulfilled  in  three  ways,  which  we 
will  consider  in  turn:  1.  Dietary  regulation,  that  is  stopping 
the  constant  intake  of  substances  which  tend  to  produce  the 
perverted  metabolism  of  cancer,  and  increasing  the  intake  of 
just  the  right  food  elements  of  nutrition:  2.  Hygienic  adjust- 
ment, that  is  such  a  regulation  of  the  various  wrong  habits  or 
conditions  of  the  patient  as  will  conduce  to  restore  a  normal 
and  ideal  blood  state:  and,  3.  Medicinal  treatment,  or  the 
proper  use  of  such  remedies  as  will  incite  the  various  organs  of 
the  body,  including  the  endocrinous  glands,  to  form  and  elimin- 
ate properly  the  effete  elements  circulating  in  the  system,  and 
effect  the  production  of  a  healthy  and  proper  blood  stream. 
It  is  readily  recognized  that  it  is  by  these  means,  and  along 
these  lines  that  medical  acumen  has  accomplished  such  marvel- 
lous results  in  tuberculosis,  reducing  its  mortality  almost  30  per 
cent  since  1900,  in  spite  of  the  continued  presence  of  tubercle 
bacillus,  while  the  death  rate  of  cancer  has  risen  almost  the 
same,  30  per  cent  during  the  same  period. 

1.  Dietary  Regulation. — Since  first  writing  on  the  subject 
under  consideration,  medical  reviewers,  and  many  others, 
including  the  daily  press,  have  spoken  as  though  I  regarded 
meat  eating  as  the  sole  cause  of  cancer,  and  that  enforced 
abstention  therefrom  was  the  single  element  necessary  for  its 
prevention  and  cure.  From  what  appears  all  through  these 
studies  it  is  readily  seen  that  this  is  by  no  means  the  case. 
But  that  I  regard  animal  protein  and  its  faulty  partition  as  a 
fertile  cause  of  the  derangement  of  metabolism  which  leads  up 
to  and  fosters  the  growth  of  cancer,  is  most  certainly  true, 
as  appears  from  what  has  preceded.  The  question  of  diet, 
however,  is  a  much  broader  one  than  that,  for  without  this 


302  CANCER 

being  correct  all  other  measures  are  of  no  avail.  For,  as  in 
gout,  the  continuance  of  over-indulgence  in  Port  and  Madeira 
wine  would  invalidate  any  attempt  to  cure  the  trouble  perma- 
nently, so  in  cancer  an  excess  of  animal  protein,  or  even  a  large 
amount  of  vegetable  protein,  militates  against  any  effort  to 
remove  the  disease  medically:  this  appears  to  be  true  also  of 
coffee  and  alcohol. 

As  diet  is  the  basic  element  upon  which  all  health,  good  and 
bad,  rests,  it  is  all  important  that  the  physician  and  patient 
come  to  a  perfect  understanding  as  to  how  the  proper  diet  in 
cancer  is  to  be  secured  and  maintained.  Moreover,  it  is  well  to 
remember  that  there  is  no  absolute  or  definite  period  during 
which  a  rightly  directed  diet  is  to  be  carried  out  or  continued: 
or  rather,  there  is  no  fixed  time  when  it  may  be  discontinued, 
lest  errors  should  induce  a  recrudescence  of  the  disease,  and 
my  patients  are  made  to  understand  that  it  is  at  their  own 
risk  that  it  is  to  be  stopped.  For  safety  from  recurrence  of 
cancer  the  proper  diet  should  be  persisted  in  indefinitely  or  even 
permanently;  for  if  the  original  errors  are  returned  to  there  is 
no  reason  why  the  disease  should  not  return.  Even  as  in 
tuberculosis  we  know  that  a  patient  may  overcome  the  disease 
by  fulfilling  all  the  necessary  conditions,  dietary,  hygienic,  and 
medicinal,  but  that  the  disease  may,  and  probably  will,  recur 
when  the  patient  resumes  exactly  the  same  life  as  before. 

It  is  often  difficult  to  make  sure  that  a  patient  will  adopt  and 
follow  faithfully  all  the  necessary  procedure  for  a  period  long 
enough  to  secure  perfect  results,  so  obsessed  is  the  medical  pro- 
fession and  the  laity  with  the  idea  that  surgery  offers  the  only 
hope  in  cancer.  But  this  can  certainly  be  accomplished,  and  I 
have  many,  many  patients  who  have  done  this  even  for  years 
or  even  indefinitely.  Some  of  these,  whom  I  have  followed  for 
years,  and  who  remain  entirely  freed  from  undoubted  cancer, 
which  had  been  previously  diagnosed  as  such  by  prominent 
surgeons,  have  told  me  that  they  have  suffered  much  more  dis- 
tress from  the  persistent  solicitations  of  their  physician,  sur- 
geons, or  friends,  urging  an  operation,  than  they  had  from  the 


MEDICAL  TREATMENT  303 

diet  and  treatment,  or  from  the  disease  itself,  as  it  slowly 
vanished  under  the  measures  employed. 

But  as  the  true  facts  regarding  the  ultimate  results  of  opera- 
tions are  becoming  known,  and  as  it  is  more  and  more  accepted 
that  the  disease  is  amenable  to  rightly  directed  dietetic,  hygienic, 
and  medicinal  treatment,  patients  are  coming  to  the  Medical 
Clinic  at  the  New  York  Skin  and  Cancer  Hospital,  and  adhering 
more  and  more  faithfully  to  treatment.  Thus  far,  however, 
these  have  been  largely  recurrent  cases,  where  further  operations 
were  impossible,  or  primarily  inoperative  cases  referred  to  me. 
To  illustrate  the  satisfactory  treatment  of  early  cases,  I  shall, 
therefore,  have  to  depend  largely  upon  those  observed  in  private 
practice  during  the  last  30  or  40  years:  for  as  yet  the  primary 
and  operative  cases  in  public  practice  are  still  referred  directly 
to  the  surgeons  of  the  hospital  for  operation. 

At  first  the  idea  of  an  absolutely  vegetarian  diet  is  distasteful 
and  seemingly  impossible  to  many  patients,  but  when  it  is  pa- 
tiently explained,  and  the  reasons  for  its  employment  and  the 
real  benefit  to  be  derived  therefrom  are  made  clear,  it  is  readily 
acquiesced  in  and  carried  out  very  faithfully.  Indeed  many  a 
patient  has  asserted  that  they  are  more  than  pleased  with  the 
general  good  feelings  resulting  from  it,  and  have  no  desire 
whatever  for  meat.  At  each  visit  I  am  particular  to  inquire 
about  this,  and  often  have  patients  bring  their  diet  card  with 
them  and  make  sure  that  all  is  right,  by  repeated  questioning. 

Among  the  poorer  classes  especially  it  has  sometimes  been 
hard  to  make  matters  clear,  and  to  secure  a  proper  diet  for  those 
attending  our  Medical  Clinic  for  Cancer.  Therefore  some  years 
ago  I  prepared  a  dietary  card  or  folder,  with  a  daily  menu,  which 
has  long  been  in  very  satisfactory  use  by  hundreds  of  patients 
in  private  and  public  practice,  and  which  is  here  reprinted. 

To  make  the  whole  matter  of  this  line  of  treatment  perfectly 
clear,  certain  statements  in  regard  to  cancer  have  been  pre- 
sented on  the  first  page,  and  on  the  last  page  some  directions 
as  to  diet  and  mode  of  life,  of  a  practical  character,  were  added, 
with  the  daily  menu  on  the  inside  pages,  to  which  particular 


304  CANCER 

attention  is  always  repeatedly  called.  At  first  there  were  one 
thousand  of  this  "Green  card  diet  slip,"  printed,  which  were 
given  to  patients  and  interested  physicians,  and  then  it  was 
somewhat  revised  and  five  thousand  were  issued,  which  have 
also  been  largely  distributed  to  physicians  all  over  the  country 
who  have  made  good  use  of  them  for  cancer  patients. 
The  complete  card,  in  full,  is  as  follows: 

New  York  Skin  and  Cancer  Hospital,  Second  Ave.  and  19th  St. 

DIRECTIONS  FOR  CANCER  PATIENTS 

i.  Cancer  is  a  serious  disease  which  should  receive  constant 
medical  care  from  time  it  is  first  suspected. 

2.  "Cancer  Specialists,"  who   advertise,  should  be  avoided. 

3.  Cancer  is  not  contagious,  and  there  is  no  danger  of  com- 
municating the  disease  to  others. 

4.  Cancer  is  not  a  disgraceful  disease,  and  there  is  no  reason 
for  being  ashamed  of  it  or  hiding  it. 

5.  As  soon  as  cancer  is  suspected,  whether  there  be  a  lump 
or  sore,  or  other  symptoms,  it  should  be  at  once  cared  for  by  a 
competent  medical  man,  as  the  earlier  it  is  rightly  treated  the 
more  prospect  there  is  of  its  being  cured. 

6.  Anything  suspected  to  be  cancer  should  not  be  handled  or 
squeezed,  but  should  be  kept  from  all  irirtation,  as  all  this 
increases  and  spreads  the  trouble  and  renders  the  cure  more 
difficult. 

7.  If  it  is  decided  that  a  surgical  operation  is  desirable  and 
wise,  this  should  be  done  very  completely  at  the  earliest  possible 
moment;  delay  is  dangerous. 

8.  The  proper  medical  treatment  of  cancer  should  never  be 
neglected,  both  at  the  very  beginning,  and  also  long  after  an 
operation  has  been  performed,  in  order  to  prevent  recurrence. 

9.  It  is  not  necessary  to  operate  on  every  cancer,  #-ray  and 
radium  are  often  of  value,  and  the  disease  can  certainly  be  made 
to  disappear  and  remain  absent  under  careful  and  efficient 
dietetic  and  medical  treatment  alone. 


MEDICAL  TREATMENT  305 

10.  This  treatment  consists  in  an  absolutely  vegetarian  diet, 
with  continuous  proper  medication,  for  a  long  time. 

n.  To  get  favorable  results  this  treatment  should  be  kept  up 
faithfully  and  strictly,  until  discontinued  by  the  physician. 

To  assist  in  carrying  out  a  strictly  vegetarian  diet,  a  diet  list 
for  cancer  is  here  given,  which  should  be  closely  adhered  to. 
Coffee,  chocolate,  and  cocoa,  as  also  alcoholic  drinks,  even  beer, 
are  harmful  and  must  be  avoided.  The  rules  given  at  the  end 
of  this  card  are  also  be  strictly  observed. 

DIET  FOR  CANCER 

Breakfast  First  Day  Dinner 

Baked  apple  5      ounces  Tapioca  soup 

4      ounces  Rice  3      ounces  Baked  potatoes 

3  ounces  Corn  bread  3      ounces  Stewed  celery 
i34  ounces  Butter  3      ounces  Peas 

3^  ounce    Sugar  1      ounce    Graham  bread 

Hot  water  or  Postum  i34  ounces  Butter 

1      Fresh  apple 
Supper 
4    ounces  Rolled  oats 
2     ounces  White  bread 
i34  ounces  Butter 
4     ounces  Stewed  prunes 
34  ounce  Sugar 
Very  weak  tea 

Second  Day 
Breakfast  Dinner 

Orange  5  ounces  Pea  soup 

4  ounces  Hominy  3  ounces  Macaroni 

2      ounces  Graham  toast  3      ounces  String  beans 

1 34  ounces  Butter  3      ounces  Carrots 

3^  ounce  Sugar  2      ounces  Bread 

Postum  1 34  ounces  Butter 

Dates 
Supper 
4      ounces  Cream  of  Wheat 
2      ounces  White  bread  toast 
1 34  ounces  Baked  apple 
2      ounces  Crackers 
i34  ounces  Butter 
3^  ounce  Sugar 
Very  weak  tea 
20 


;o6 


CANCER 

Third  Day 

Dinner 

5 

ounces  Corn  soup 

3 

ounces  Baked  potatoes 

3 

ounces  Squash 

3 

ounces  Boiled  onions 

2 

ounces  Bread 

iH 

ounces  Butter 

Raisins 

Breakfast 
Banana 

4      ounces  Pettijohn 
2      ounces  White  bread 
\Y±  ounces  Butter 
^■>  ounce    Sugar 
Hot  water  or  Postum 


Supper 
4      ounces  Farina 
4      ounces  Stewed  figs 
2      ounces  Graham  crackers 
\Yi  ounces  Butter 
}£    ounce  Sugar 
Very  weak  tea 
Fourth  Day 
Breakfast 
Raw  apple 
4      ounces  Cornmeal  mush 
2      ounces  Graham  bread 
1%  ounces  Butter 
Yi  ounce  Sugar 
Postum. 


Dinner 
ounces  Vegetable  soup 
ounces  Baked  beans 
ounces  Cauliflower 
ounces  Asparagus 

2      ounces  Bread 

i]4  ounces  Butter 
Figs 


Supper 
4      ounces  Rice 
4      ounces  Stewed  prunes 
2      ounces  Graham  crackers 
1%  ounces  Butter 
}i  ounce  Sugar 
Very  weak  tea 
Fifth  Day 
Breakfast 
Orange  5 

4      ounces  Cracked  wheat  4 

3      ounces  Corn  muffins  3 

i}£  ounces  Butter  3 

}i  ounce  Sugar  2 

Hot  water  or  Postum 


Dinner 
ounces  Sago  soup 
ounces  Spaghetti 
ounces  Lima  beans 
ounces  Boiled  onions 
ounces  Bread 
1 34  ounces  Butter 
Dates 
Supper 
4      ounces  Cream  of  wheat 

Sliced  orange 
2      ounces  Oatmeal  crackers 
1  li  ounces  Butter 
3-4  ounce    Sugar 
Very  weak  tea 


MEDICAL  TREATMENT  307 


Sdcth  Day 

Breakfast 

Dinner 

4       ounces  Samp 

5      ounces  Celery  soup 

2      ounces  Graham  toast                      4      ounces  Baked  potatoes 

1%  ounces  Butter 

3      ounces  Carrots 

^  ounce    Sugar 

3      ounces  Spinach 

Postum 

2      ounces  Bread 

iJ4  ounces  Butter 

Orange 

Supper 

4 

ounces  Wheatena 

4 

ounces  Stewed  figs 

2 

ounces  Saltine  biscuit 

iH 

ounces  Butter 

H 

ounce    Sugar 

Very  weak  tea 

Repeat  this  bill  of  fare  on  successive  days. 

Some  interchange  of  the  different  articles  may  be  made 
according  to  the  season  and  to  suit  the  appetite,  or  convenience 
of  patients;  but  in  the  main  this  bill  of  fare  should  be  followed, 
with  occasional  substitution  of  similar  articles,  if  necessary. 

Bread,  preferably  from  whole  wheat,  at  least  24  hours  old 
may  be  taken  as  desired. 

A  little  old  cheese  may  be  grated  on  the  macaroni  and 
spaghetti,  but  not  cooked  with  it. 

One  boiled  or  poached  egg  may  be  taken  for  breakfast  every 
other  day,  and  very  fat  bacon  on  the  alternate  days,  unless 
otherwise  directed  by  the  physician. 

It  is  desirable  to  eat  the  skin  of  potatoes,  baked  or  boiled. 

Each  and  every  meal  should  be  eaten  very  slowly,  for  at 
least  half  an  hour,  with  long  chewing. 

One  tumbler  of  water,  not  iced,  is  to  be  taken  with  each 
meal,  but  not  when  food  is  in  the  mouth ;  also  a  tumbler  full  of 
hot  water,  one  hour  before  breakfast  and  one  hour  before 
supper. 

No  milk  is  to  be  taken  unless  specially  ordered. 

The  vegetable  soups  are  to  be  made  from  a  stock  composed 
of  the  water  in  which  all  vegetables,  iucluding  potatoes,  have 
been  boiled,  added  to,  day  by  day,  kept  hot,  and  allowed  to 


308  CANCER 

evaporate;  a  portion  is  each  day  thickened  as  desired  with 
cereals,  farina,  sago,  vermicelli,  etc.  No  meat  stock  is  to  be 
added. 

The  cereals  are  to  be  boiled  with  water,  three  or  four  hours, 
and  may  be  cooked  in  the  afternoon  and  re-heated  in  the  morn- 
ing, adding  more  water.  Rice,  farina,  and  cream  of  wheat 
require  only  one  hour.  Chopped  dates,  figs,  raisins,  or  currants 
may  be  added  to  cereals  when  desired. 

All  the  cereals  are  to  be  served  very  hot,  on  hot  plates,  and 
eaten  with  butter  and  salt  to  taste  (not  milk  and  sugar).  They 
are  to  be  eaten  very  slowly,  with  a.  fork,  and  very  well  chewed. 

The  crackers  with  supper  may  be  varied  to  suit  the  taste; 
they  should  be  eaten  dry,  with  butter,  and  chewed  very 
thoroughly. 

Nothing  should  be  taken  between  meals,  unless  especially 
directed,  and  the  life  should  be  as  simple  and  healthful  as 
possible,  with  early  and  long  bed  hours. 

L.  Duncan  Bulkley,  M.  D. 

This  diet  was  prepared  with  the  assistance  of  the  dietitian 
of  the  hospital,  and  represents  an  average  of  2,100  calories  per 
day,  with  140  of  vegetable  protein.  This  is  calculated  for  a  per- 
son of  about  150  lb.,  either  in  bed  or  not  taking  much  active 
exercise.  The  quantity  of  each  article  may,  of  course,  be 
increased  or  diminished  for  lighter  or  heavier  weights,  but  in 
the  main  this  menu  has  sufficed,  so  that  fat  persons  have  come 
to  nearer  normal  weight  and  thin  persons  have  gained  in  weight. 
I  have  records  of  one  hospital  patient,  whose  case  will  be 
reported  later,  with  a  frightful  sarcoma  of  the  upper  cheek,  who 
completely  recovered.  She  weighed  89^  lb.  on  entering  the 
hospital,  and  some  months  later,  when  I  showed  her  at  my 
lecture,  with  the  hole  perfectly  covered  with  a  thick  skin  graft, 
she  weighed  130  lb.,  absolutely  on  this  diet  alone,  with 
medication. 

On  the  last  page  of  the  folder  are  certain  directions  which 
are  necessary  to  have  acted  upon,  and  about  which  I  frequently 


MEDICAL  TREATMENT  309 

question  patients.  An  important  one  is  that  with  regard  to 
slow  eating  and  perfectly  masticating  and  insalivating  the  food, 
at  each  meal,  even  cereals,  for  at  least  half  an  hour.  Note 
also  that  the  cereals  are  to  be  eaten  with  butter  and  salt,  and 
not  with  milk  and  sugar,  and  should  always  be  eaten  with  a 
fork,  and  not  with  a  spoon,  in  order  to  encourage  slow  eating 
and  chewing.  I  have  already  called  attention  to  this,  instancing 
the  remarkable  results  obtained  by  Mr.  Fletcher,  which  Dr. 
Chittenden  verified,  and  the  word  "  fletcherism  "  is  a  valuable 
addition  to  our  vocabulary  in  explaining  this  to  patients.  It 
is  to  be  remembered  that  in  an  earlier  chapter  the  salivary 
secretion  was  mentioned  as  at  fault  even  in  early  cases  of 
cancer,  and  this  perfect  mastication  is  intended  to  stimulate 
the  salivary  glands  and  facilitate  the  change  of  starchy  food 
into  glucose,  the  first  step  in  digestion,  without  which  later 
processes  must  be  defective:  for  the  rapid  eating  of  modern 
days  may  be  one  of  the  contributing  basic  causes  of  the  per- 
verted nutrition  leading  up  to  cancer. 

Attention  is  also  called  to  the  preparation  of  the  vegetable 
soup,  which  is  to  be  employed  in  place  of  the  meat  stock  which 
is  ordinarily  used,  which  latter  naturally  contains  the  most 
poisonous  extract  of  meat,  (with  which  dogs  have  been  killed 
in  the  laboratory),  or  with  milk,  which  is  not  desirable.  This 
vegetable  stock,  (made  from  all  the  vegetables  used  by  the 
family),  contains  all  the  salts  and  other  valuable  extracts  from 
the  vegetables,  which  are  commonly  thrown  away,  to  the  great 
detriment  of  nutrition.  For  we  have  already  seen  what  an 
important  part  mineral  salts  play  in  the  constitution  of  the 
body  and  its  cells.  A  portion  of  this  vegetable  stock  for  soup 
is,  to  be  thickened  and  flavored  as  desired  each  day,  some 
butter  being  added,  as  also  cooked  and  chopped  vegetables, 
various  cereals,  macaroni,  vermicelli,  tapioca,  sago,  etc.  I 
may  add  that  many  patients  in  private  practice  have  declared 
that  their  families  pronounced  this  the  best  soup  thay  had  ever 
tasted,  to  which  I,  myself,  can  also  bear  witness. 

Attention  has  already  been  called  to  the  great  loss  of  nutritive 


310  CANCER 

elements  in  the  modern  or  common  preparation  of  many 
articles  of  food.  The  loss  of  vitamines  and  minerals  in  the 
refinement  of  wheat  flour  is  also  serious,  and  whole  wheat 
preparations  should  be  more  freely  used  in  these  cases.  Also 
some  one  has  called  attention  to  the  loss  of  mineral  and  other 
substances  in  the  refinement  of  sugar,  and  brown  sugar  and 
old  fashioned  molasses,  and  maple  sugar,  and  honey  are  more 
desirable.  The  United  States  Agricultural  Experiment  Bureau 
tells  us  that  30  per  cent  of  the  nutritive  value  of  potatoes  is 
ordinarily  wasted  in  the  common  method  of  roughly  peeling 
and  cooking  them:  the  inner  skin  contains  a  large  amount, 
indeed  about  all,  of  the  mineral  content  and  most  of  the  proteids. 
Hutchinson  tells  us  that:  "If  a  bushel  of  potatoes  were  peeled 
and  soaked  before  being  boiled,  the  loss  of  nutrients  would  be 
equivalent  to  the  amount  contained  in  a  pound  of  beefsteak. " 
For  this  reason  I  have  advised  that  the  skin  of  potatoes,  baked 
or  boiled,  should  be  eaten. 

It  will  be  noticed  in  the  menu  that  the  use  of  butter  is  encou- 
raged, a  quarter  of  a  pound  being  given  daily,  divided  into 
three  portions,  one  at  each  meal.  This  quarter  of  a  pound  con- 
tains 800  calories  or  one-third  of  the  total  amount  ordinarily 
required,  and  is  easily  digestible.  Hutchinson1  says:  "There 
is  no  likelihood  of  this  quantity  surpassing  the  absorptive 
powers  of  the  intestine,"  Sugar  also  is  prescribed  in  reasonable 
quantity,  affording  an  additional  carbohydrate,  which  is  com- 
pletely oxidyzed  under  favorable  conditions. 

It  is  realized,  of  course,  that  this  bill  of  fare  can,  and  undoubt- 
edly will  be  improved  upon.  But  is  was  complied  with  con- 
siderable care  and  thought,  and  an  experience  with  it  now  for 
some  years  in  hundreds  of  cases,  both  of  cancer  and  other  dis- 
eases, shows  that  it  is  workable,  and  it  has  accomplished  results 
which  are  often  surprising  and  most  gratifying,  both  in  my 
public  and  private  practice,  and  also  in  the  hands  of  other 
physicians.  It  was  prepared  primarily  for  hospital  practice, 
among  the  poorer  and  uneducated  classes,  of  all  nationalities, 

1  Hutchinson,  "  Food  and  the  Principle  of  Dietetics."    New  York,  1911,  p.  12. 


MEDICAL  TREATMENT  311 

and  perhaps  there  are  many  other  articles  similar  to  those 
named  which  might  be  taken  with  advantage. 

Heretofore  I  have  not  advised  the  use  of  much  fruits, 
especially  raw,  fearing  the  acid  element  in  them,  but  since 
reading  recently,  for  the  first  time,  all  or  most  of  the  writings  of 
Dr.  Robert  Bell  of  London,  I  am  inclined  to  believe  that  they 
are  beneficial,  as  also  more  of  raw  vegetable  products,  lettuce, 
celery,  tomatoes,  etc.,  also  nuts.  He  likewise  advocates  the 
use  of  cheese  and  milk  much  more  than  I  allow:  though  I  have 
been  accustomed  to  give  blood-warm  milk,  drank  pure  and 
alone,  without  a  particle  of  food  with  it,  full  half  an  hour  to  an 
hour  before  meals,  to  those  who  seemed  to  need  more 
nourishment. 

In  the  former  chapter  I  mentioned  the  rarity  of  cancer 
among  vegetarian  nations,  and  I  may  quote  my  own  personal 
experience  in  the  matter,  as  written  on  my  return  from  visiting 
many  of  them.  During  a  rather  extensive  trip  through  the  Far 
East  I  was  unable  to  see  or  even  to  hear  of  any  cancer,  although 
I  met  a  large  number  of  medical  men,  and  made  diligent  inquiry 
regarding  the  same.  As  I  wished  to  verify  my  views  in  regard 
to  the  rarity  of  the  occurrence  of  cancer  among  those  who  lived 
on  rice  or  other  vegetarian  diet,  I  visited  many  civil,  military, 
and  missionary  hospitals,  with  a  total  of  many  thousands  of 
patients,  and  ministering  to  many  millions  of  population. 
In  Japan,  Korea,  China,  The  Philippines,  India,  Siam,  and 
Egypt  I  met  with  the  same  response,  that  cancer  was  rarely  seen 
among  these  vegetarian  nations.1 

In  India  all  writers  agree  that  cancer  is  rare  among  the 
inhabitants  of  warmer  country  districts,  where  they  live 
largely  on  rice  and  millet,  with  a  little  milk  and  butter  and 
vegetables.  They  eat  meat  rarely,  the  immense  majority  of 
the  people  live  a  rural  life,  depending  largely  upon  agriculture 
for  their  sustenance. 

Of  late  years  some  have  endeavored  to  show  that  cancer  was 
more  prevalent  in  India  than  previously  supposed.     But  its 

1  Bulkley,  "  Cancer,  Its  Cause  and  Treatment."    New  York,  1915,  p.  56. 


3i2  CANCER 

incidence  still  bears  no  real  relation  to  that  occurring  in  other 
countries,  and  an  analysis  of  some  recent  reports  explains  in  an 
interesting  and  curious  manner  the  reasons,  for  the  diversity 
of  opinion  as  to  the  actual  frequency  of  the  disease,  as  has  been 
already  mentioned. 

Thus  Benratt1  could  collect  a  total  of  only  1,700  cases  of 
cancer  from  5  years'  statistics  of  15  Mission  Hospitals  and  34 
Government  Hospitals  in  India,  representing  of  course,  very 
many  millions  of  inhabitants,  whereas  in  New  York  City  alone, 
according  to  the  weekly  Bulletin  of  the  Board  of  Health,  there 
were  2,691  deaths  from  cancer  during  the  six  months  from  July 
1st  to  December  31st  1920,  in  a  population  of  only  about  six 
million. 

Moreover,  of  these  1,700  cases  reported  as  cancer  by  Benratt, 
there  were  1,200  about  the  mouth,  the  greater  share  of  these 
arising  from  the  very  common  habit  of  "chewing betel."  The 
substance  chewed,  or  held  in  the  mouth  a  long  time,  is  composed 
of  tobacco,  betel  leaves,  areca  nut,  and  slaked  lime,  the  mass 
being  held  in  the  cheek,  back  in  the  mouth,  where  the  lesions 
usually  occur. 

Sandwith2  also  attempts  to  show  that  cancer  is  prevalent  in 
India,  but  refers  to  only  2,000  cases  reported  in  the  hospitals 
there,  in  3  years,  also  among  many  millions  of  people,  and  he 
refers,  likewise,  to  the  betel  chewing  cancer,  and  to  the  "kangri 
burn,"  on  the  abdomen  of  men,  from  the  charcoal  furnace 
worn  there  for  warmth.  These  peculiar  local  disorders  cer- 
tainly vitiate  any  deductions  which  could  be  drawn  from  such 
statistics.  Again  Bashford  and  others  have  endeavored  to 
overturn  the  generally  accepted  view  of  the  rare  occurrence  of 
cancer  in  the  Far  East,  but  a  careful  study  of  the  evidence 
presented  shows  much  the  same  inadequacy  of  proof,  and 
cannot  at  all  weigh  against  the  reports  and  unprejudiced 
opinion  of  most  capable  medical  men  who  have  long  lived  and 
practised  in  those  regions,  some  of  whom  as  medical  mission- 

1  Benratt,  Indian  Medical  Gazette,  1908,  p.  452. 
3  Sandwith,  Clinical  Journal,  1910,  p.  409. 


MEDICAL  TREATMENT  313 

aries  of  unusual  ability  have  had  most  intimate  contact  and 
acquaintance  with  the  natives.  Not  long  ago  a  very  bright 
and  strong  medical  missionary,  who  has  long  been  connected 
with  the  medical  college  and  hospital  in  Beirut,  Syria,  told  me 
that  cancer  was  practically  unknown  among  the  thousands  of 
patients  who  flock  there  from  all  over  the  Near  East;  he  adding 
that  they  were  all  largely  vegetarians. 

2.  Hygienic  adjustment,  that  is,  such  a  regulation  of  the 
various  wrong  habits  or  conditions  of  the  patient  as  will  conduce 
to  restore  a  normal  and  ideal  blood  state.  We  know  what  this 
will  do  for  tuberculosis,  but  strangely  enough  practically  no 
attention  to  this  is  ordinarily  applied  to  cancer.  The  details 
may  seem  simple  and  homely,  but,  as  close  attention  to  details 
is  most  important  in  antiseptic  or  aseptic  surgery,  so  in  cancer 
no  detail  is  too  small  which  can  have  a  good  or  bad  effect  on  the 
state  of  the  blood  current  which  induces  the  wrong  action  of  the 
cells  of  the  body  and  favors  their  erratic  and  destructive  course. 

As  uncontaminated  oxygen  is  essential  to  give  the  tuberculo- 
sis patient  the  power  to  resist  the  inroads  of  the  tubercle 
bacillus,  so  imperfect  oxygenation  of  the  material  which  enters 
and  composes  the  blood  is  injurious  in  cancer.  Attention 
should  therefore  be  paid  to  ventilation  and  drainage,  and  every 
source  of  contamination  of  the  atmosphere  surrounding  these 
patients  should  be  removed. 

Sunlight  we  know  is  essential  for  perfect  animal  and  vegetable 
life,  and  must  have  its  effect  on  the  vitality  of  cancer  patients. 
Unfortunately  many  of  the  poor  creatures  who  have  to  go  to 
hospitals  or  cancer  retreats  are  seldom  fully  and  perfectly 
ministered  to  in  regard  to  either  oxygen  or  sunlight. 

Sleep  is  nature's  sweet  restorer,  and  attention  should  be  paid 
to  this,  both  in  the  early  and  late  stages  of  cancer.  All  know 
that  of  late  years  the  errors  in  regard  to  this  are  very  gross. 
The  normal  8  hours  of  sleep  should  be  secured  and  the  avoidance 
of  late  bed  hours  should  be  insisted  on,  the  patient  being  in  bed 
and  lights  out  by  10:30  p.  m.  Early  sleep  is  certainly  more 
refreshing  than  that  begun  late  and  prolonged  into  the  morning 


314  CANCER 

hours.  Morphine  and  all  opiates  given  to  secure  sleep  are 
certainly  harmful,  as  I  have  long  observed,  and  they  only 
increase  the  real  disease  by  interfering  with  the  action  of  the 
endocrinous  glands,  and  checking  the  secretions  and  excretions, 
thereby  vitiating  the  blood  stream.  As  remarked  elsewhere, 
when  proper  treatment  of  all  kinds  is  carefully  carried  out  they 
are  seldom  required,  and  it  is  the  rarest  thing  for  any  of  my 
patients  ever  to  require  or  have  them,  even  up  to  a  fatal  termi- 
nation of  the  disease:  patients  will  die  peacefully,  without  an 
ache  or  pain ;  in  very  many  instances  opiates  previously  ordered 
by  others  have  been  abandoned  voluntarily  and  entirely,  soon 
after  getting  under  proper  treatment. 

Regularity  of  habits  certainly  conduces  to  perfect  health,  as 
is  exemplified  in  those  in  training  for  athletics,  as  also  in  the 
army  and  navy. 

I  insist  on  perfect  regularity  of  meal  hours,  rest,  sleep,  and 
recreation.  Eating  between  meals,  of  sweets  or  of  anything, 
is  conductive  to  more  or  less  disturbances  of  digestion  and  meta- 
bolic action,  and  must  be  prevented. 

Recreation  is  a  much  misunderstood  matter,  and  should  be 
looked  into.  For  instead  of  its  being  a  re-creation  of  the  vital 
powers,  it  is  often  as  wreck-creation  of  them.  One  can  readily 
overdo  recreation.  Excessive  fatigue  certainly  interferes  with 
perfect  digestion  and  assimilation,  and  lowers  bodily  vigor. 
Dissipation  primarily  means  a  wasting,  scattering,  or  squander- 
ing anything,  and  many  a  person's  health  is  dissipated  by  ' '  pursu- 
ing pleasure  to  excess,"  as  the  dictionary  has  it. 

Mental  and  nervous  states  have  also  much  to  do  with  bad  and 
good  digestion  and  assimilation,  and  several  writers  have  insisted 
that  great  nerve  strain  and  fright  have  induced  cancer.  This  is 
quite  possible,  both  by  their  influence  in  arresting  or  delaying 
digestion,  and  by  direct  innervating  influence  on  cell-life, 
through  the  sympathetic  and  vaso-motor  nervous  systems.  In 
one  interesting  case  of  cancer  of  the  breast,  to  be  reported  later, 
I  felt  pretty  certain  that  prolonged  nervous  strain,  from  many 
deaths  and  insanity  in  the  family  was  the  predominating  cause 


MEDICAL  TREATMENT  315 

of  the  disease.  The  effect  of  nerve  influence  on  digestion  was 
observed  a  while  ago  in  some  cats  under  #-ray  examination. 
When  well  fed  and  happy  the  intestinal  peristaltic  action  pro- 
gressed perfectly,  but  when  the  same  cats  were  then  greatly 
irritated  purposely,  all  intestinal  movements  ceased. 

In  attempting,  therefore,  to  control  early  or  late  cancer,  every 
possible  element  which  can  influence  assimilation  and  disassi- 
milation,  or  anabolism  and  catabolism  badly,  must  be  carefully 
guarded  against  hygienically,  if  we  would  place  the  system  in  a 
condition  to  resist  inroads  of  cancer.  All  these  matters  which 
have  been  referred  to  may  seem  to  be  homely  and  trite,  but  long 
experience,  which  is  more  or  less  verified  by  other  observers, 
shows,  by  the  results  obtained  in  overcoming  the  disease,  that 
they  are  of  importance.  And  in  regard  to  the  points  mentioned 
in  regard  to  both  diet  and  hygiene,  they  are  well  worth  while,  if 
they  can  help  stay  the  ever  increasing  horrors  of  the  morbidity 
and  mortality  of  cancer,  which  surgeons  acknowledge  cannot  be 
accomplished  by  operations,  stating  that  we  know  nothing  of 
its  cause.  And  experience  has  shown,  in  the  hands  of  a  number 
of  practitioners,  that  with  all  this  care,  together  with  proper 
internal  remedies,  this  end  can  be  accomplished.  Experience 
also  shows  that  a  certain  number  of  patients  will  gladly 
follow  whatever  course  is  necessary,  especially  when  they  see 
the  benefits  therefrom  in  the  disappearance  of  malignant  tumors. 
The  tuberculotic  patient  undergoes  any  amount  of  privation 
and  discomfort  in  the  endeavor  to  overcome  the  disease. 

3.  Medical  Treatment. — This  includes  the  proper  use  of  such 
remedies  as  will  incite  the  various  organs,  including  the  endo- 
crinous glands,  to  form  and  eliminate  properly  the  effete  ele- 
ments circulating  in  the  system,  and  to  effect  the  production 
of  a  healthy  and  ideal  blood  stream 

Unfortunately  the  historical  path  of  cancer  is  strewn  with  the 
wrecks  of  blasted  hopes  regarding  various  remedies,  quack  and 
other,  whose  virtues  for  the  cure  of  the  disease  have  been  her- 
alded for  a  while,  only  to  sink  into  oblivion,  to  the  sad  disap- 
pointment of  trusting  sufferers  from  the  dire  malady.    Various 


3i6  CANCER 

serums  have  been  tried,  with  varying  success,  partially  from 
psychic  reasons,  but  these  too  have  gone  the  way  of  the  others. 
These  and.  also  .r-rays  and  Radium  have  been  considered  in 
former  chapters.  The  reason  of  all  this  failure  is  found  in  the 
fact  that  many  of  them  were  empirical  and  not  founded  on  a 
scientific  basis.  As  already  intimated,  medicinal  measures  are 
really  valuable  only  as  based  on  knowledge  and  experience  and 
on  a  correct  judgment  in  regard  to  the  result  or  effect  desired 
to  be  produced,  and  in  conjunction  with  proper  diet  and  hy- 
giene as  detailed  in  this  chapter. 

It  must  first  be  clearly  appreciated  and  understood  that  there 
is  no  one  remedy  or  single  course  of  treatment  which  is  to  be 
invariably  followed,  or  is  always  successful  in  every  case  of 
cancer.  And  probably  there  will  never  be  such  found,  as  may 
be  judged  from  what  has  preceded  in  this  and  other  chapters. 

In  a  disease  about  which  there  seems  to  be  such  uncertainty 
of  opinion  as  to  the  absolute,  final,  and  integral  cause  of  the 
particular  deviation  from  normal  tissue  growth,  and  the  produc- 
tion of  such  vicious,  destructive  cells  as  in  cancer,  the  remedies 
which  may  be  required  in  different  cases,  to  meet  varied  condi- 
tions, are  as  varied  as  are  the  peculiarities  of  the  individual. 
The  treatment  requires  the  utmost  diligence  and  attention  to 
details  on  the  part  of  both  the  physician  and  patient,  and  over 
a  length  of  time  which  it  may  be  difficult  to  secure.  This  is 
quite  different  from  simply  performing  a  relatively  brief  surgical 
operation,  after  which  the  patient  is  dismissed,  with  the  vain 
hope  that  the  disease  will  not  return,  but  with  no  precautions 
taken  against  recurrence. 

Patience  and  perseverance,  with  much  thought  and  medical 
acumen  are  the  first  requisites — but  before  this  there  must  be  a 
thorough  belief  and  confidence  in  the  statements  which  have 
been  made,  the  correctness  of  the  theory,  and  the  value  of  the 
methods  employed.  With  this  there  must  also  be  an  optimism 
on  the  part  of  the  physician  which  begets  a  confidence  on  the 
part  of  the  patient,  which  will  do  much  toward  reaching  the 
desired  result.     Unless  much  time,  thought,  study,  and  effort 


MEDICAL  TREATMENT  317 

can  be  given  to  each  case  of  cancer,  I  should  deprecate  any 
attempt  to  treat  it  medically,  and  rather  risk  at  once  the  chances 
of  the  best  surgery,  poor  as  they  are.  It  was  for  fear  of  harm 
following  an  incomplete  understanding  of,  and  an  imperfect 
or  careless  carrying  out  of  the  line  of  practice  which  I  had 
pursued  satisfactorily  for  30  or  40  years,  that  I  hesitated  and 
delayed  so  long  before  urging  it  generally,  for  the  first  time 
over  6  years  ago.  But  the  continued  and  steady  rise  in  mor- 
tality from  cancer  under  the  ordinarily  accepted  treatment, 
compels  me  more  and  more  to  attempt  to  make  clear  whatever 
study  and  experience  have  taught  me  to  be  the  correct  view  of 
its  nature  and  cause,  and  the  approximately  correct  treatment 
of  the  disease  carcinosis. 

From  what  has  preceded  it  will  be  seen  at  once  that  rational 
and  right  internal  treatment  must  proceed  and  continue  along 
the  lines  indicated  relating  to  the  bio-chemistry  of  cancer  as  a 
disease,  and  not  simply  with  reference  to  its  local  manifestations 
as  they  may  appear  in  various  parts  of  the  body,  either  primar- 
ily or  as  the  result  of  its  spreading  by  metastasis.  Some  tissue 
cells  have  broken  loose  from  their  normal  physiological  state, 
and  have  taken  on  a  wrong  and  rampant  action,  of  a  reproduct- 
ive character,  owing  to  an  erroneous  metabolism,  which  has 
induced  a  deranged  or  disordered  blood  current.  This  dis- 
ordered metabolism  has,  in  turn  been  produced  by  a  multipli- 
city of  causes,  including  dietary  errors,  by  faulty  action  of  some 
of  the  organs  of  the  body,  and  measures  are  to  be  devised 
and  carried  out  to  restore  the  bodily  functions  to  a  normal 
state. 

The  first  line  of  treatment,  therefore,  after  the  prevention  of 
the  introduction  into  the  system  of  harmful  elements,  and  the 
providing  of  suitable  material  for  the  building  up  of  healthy 
body  cells,  by  dietary  measures,  and  removing  wrong  hygienic 
features,  is  then  to  seek  by  medicinal  agents,  to  restore  the 
various  bodily  secretions  to  the  normal. 

Constipation,  or  rather  imperfect  intestinal  excretion,  has 
been  recognized  by  many  as  an  important  element  in  the 


318  CANCER 

causation  of  cancer,  by  means  of  the  auto-intoxication  resulting 
therefrom;  and  this  condition  I  have  found  to  exist  almost 
invariably  in  the  subjects  of  cancer,  even  long  before  any  special 
harm  therefrom  was  suspected,  and  also  in  the  very  early  stages 
of  the  disease,  and  long  before  such  a  derangement  has  been 
induced  by  opiates  given  for  pain.  Dr.  Bell  is  even  more 
positive  than  I  am,  as  to  the  invariable  occurrence  of  imperfect 
intestinal  excretion,  or  intestinal  stasis,  in  cancer  patients,  and 
of  the  relation  of  a  stagnant  colon  to  cancer. 

Imperfect  intestinal  excretion  is  a  large  subject,  about  which 
much  has  been  written,  and  it  is  difficult  to  compass  what  should 
be  said  in  regard  to  it  in  a  brief  space:  but  it  is  very  essential 
in  the  medical  treatment  of  cancer  to  secure  what  is  really  an 
ideal  action  of  the  intestinal  canal,  which,  unfortunately,  is 
by  no  means  the  common  condition  found  in  these  patients, 
and  some  attention  must  now  be  given  to  this  homely  subject. 

Long  experience  has  taught  me  that  it  is  not  at  all  enough 
simply  to  ask  patients  if  the  bowels  are  regular,  which  will 
often  be  answered  in  the  affirmative,  when  this  is  far  from 
being  the  real  truth.  Repeatedly  it  is  found,  on  most  careful 
inquiry,  that  they  endeavor  to  keep  them  so  by  some  mineral 
water  or  oil,  or  by  some  advertised  remedies,  so  that  one  must 
question  them  if  such  are  ever  used,  or  perhaps  remedies  from 
another  practitioner.  And  often  it  occurs  that  there  is  not  that 
complete  emptying  of  the  rectum  which  belongs  to  perfect  health, 
accompanied  with  that  comfortable  feeling  which  all  recognize 
when  this  has  been  accomplised,  Bell1  says:  "I  am  convinced 
that  constipation  constitutes  a  most  potent  predisposing  cause 
to  cancer,  and  is  invariably  present  when  cancer  crops  up. 
A  complete  evacuation  every  24  hours  must  be  insisted  upon,  for 
many  are  under  the  impression  that  if  their  bowels  are  moved 
once  a  day,  no  matter  what  the  character  of  the  stool  is,  every- 
thing is  satisfactory  in  this  respect:  whereas,  in  innumerable 
instances  which  I  have  come  across,  I  have,  on  close  ques- 
tioning, ascertained  that  the  bowel  has  by  no  means  been 

1  Bell,  "  Cancer,  Its  Cause  and  Treatment  without  Operation."     1913,  p.  197. 


MEDICAL  TREATMENT  319 

thoroughly  relieved  or  emptied  at  the  time.  In  these  in- 
stances the  character  of  the  stool  has  been  quite  sufficient  to 
prove  that  the  feces  have  been  retained  for  an  undue  length 
of  time  within  the  colon,  the  result  being  that  the  greater 
portion  of  the  liquid  has  been  absorbed  into  the  blood,  and  we 
know  that  this  cannot  occur  without  interfering  sadly  with 
its  purity."  Colonic  absorption  is  being  more  and  more 
recognized  as  the  source  of  various  diseases,  and  the  possibilities 
of  fecal  retention  in  this  location  was  most  remarkably  demon- 
strated in  a  case  which  came  under  my  observation  in  one  of 
the  hospitals  of  this  city.  A  great  solid  mass  was  found  in  a 
woman's  upper  abdomen,  and  suspecting  that  it  might  be 
cancerous  an  exploratory  incision  was  made,  and  revealed  only 
an  enormously  distended  transverse  colon,  between  4  and  5 
inches  in  diameter.  This  was  removed  and  was  said  to  contain 
nearly  2  quarts  of  impacted  feces,  with  an  opening  through  the 
centre,  by  means  of  which  the  bowels  had  a  regular  action,  as 
also  free  movement  induced  before  the  operation. 

It  is  not  enough  to  give  general  directions  to  patients  in 
regard  to  the  action  of  the  bowels,  or  to  leave  the  matter  of 
therapeutic  measures  to  their  discretion.  Definite  and  careful 
directions  should  be  given  and  the  actual  remedies  directed 
to  be  used,  together  with  explict  directions  as  to  the  exact 
method  of  their  employment,  and  careful  inquiry  should 
continually  be  made  as  to  the  results.  Lorand1  is  very  clear 
and  strong  upon  the  ill  results  from  the  retained  excretory 
products  in  the  large  intestine.  "The  bacteria  of  the  intestine 
exert  their  decomposing  action  upon  any  constituents  of  the 
food  which  have  escaped  digestion  by  the  gastric  and  intestinal 
juices.  When  a  person  has  ingested  a  large  quantity  of  meat, 
it  may  happen  that  a  portion  of  it  will  reach  the  intestine  still 
undigested,  and  here  the  bacterial  action  will  very  decidedly 
come  into  play.  The  body,  however,  cannot  derive  any  nutri- 
tive benefit  from  the  action  of  the  decomposing  bacteria  upon 
the  albumen  in  the  large  intestine,  for,  even  though  the  result- 

1  Lorand,  "Health  through  Rational  Diet."     Philadelphia,  1916,  p.  44. 


320  CANCER 

ing  products  may  be  absorbed,  they  are  not  assimilated  in  the 
same  manner  as  other  albumenoid  nutriments,  but  on  the 
contrary  may  exert  an  injurious  and  even  poisonous  action. 
Indeed  the  general  symptoms  occurring  after  long-continued 
constipation,  such  as  headache,  nausea,  mental  depression, 
loss  of  appetite,  etc.,  may  be  referred  to  the  absorption  of  such 
poisonous  products.    .    . 

"During  their  progress  through  the  intestine,  all  the  fluids 
and  other  portions  of  the  food  which  are  capable  of  being 
absorbed,  are  taken  up,  and,  the  farther  the  mass  progresses 
downwards,  the  more  its  liquid  constituents  are  given  up, 
until  only  dry  feces  remain.  The  longer  the  feces  remain  in 
the  intestine  the  harder  they  become.  When  the  diet  consists 
principally  of  meat,  the  feces  tend  to  be  dry,  but  with  more 
carbohydrates,  especially  in  the  form  of  sweets,  they  are  more 
liquid."  The  absorptive  power  of  the  lower  intestine  is  recog- 
nized by  all,  when  we  remember  that  patients  may  be  fed  by 
the  bowel  for  weeks  and  even  months,  and  that  medicines, 
alcohol,  and  even  ether  are  effective  when  thus  administered. 

Kidney  action,  good  or  bad,  has  repeatedly  been  mentioned 
as  an  element  of  great  importance  in  connection  with  the 
development  and  continuance  of  cancer,  and  this  is  a  matter 
which  should  receive  constant  and  serious  consideration  in 
attempting  to  control  cancer.  As  we  recognize  that  the  kidneys 
are  only  niters,  seeking  to  remove  obnoxious  material  from  the 
arterial  blood,  their  secretion  should  be  watched,  with  repeated 
volumetric  analyses,  and  agencies  are  to  be  employed  to  make  it 
that  of  health,  which  is  seldom  the  case.  I  have  had  many 
cases  in  which  the  urine  was  all  saved  each  day,  measured  and 
recorded,  for  months,  and  even  for  a  year  or  two,  with  careful 
analyses  made  and  recorded  weekly,  or  at  stated  periods.  It  is 
interesting  to  note  how  the  kidney  secretion  improves  as  the 
cancerousmass  improves  under  most  careful  medicinal  guidance. 
And  the  saliva,  which  has  been  acid  regains  its  normal  alkalinity. 
The  importance  of  proper  salivary  action,  and  through  mastica- 
tion has  been  considered  in  a  previous  chapter. 


MEDICAL  TREATMENT  321 

In  regard  to  the  actual  medical  treatment  employed  it  is 
difficult  to  speak  clearly  and  briefly,  for  during  a  prolonged 
course  there  may  be  any  number  and  variety  of  remedies  used  to 
meet  the  varied  condition  of  the  patient.  But  in  the  New 
York  Skin  and  Cancer  Hospital,  and  also  in  private  practice, 
these  patients  are  almost  always  first  given  a  certain  mixture, 
in  varying  proportions,  which  for  years  has  rendered  the  most 
admirable  service.  The  mixture  is  as  follows:  R.  Potassii 
acetatis  5iTinct.  nucisvom.  3iv.  Extract,  cascar.  fld  5i-5iv, 
Extract,  rumicis  radicis  fluid  ad  5  iv.  The  amount  of  cascara 
is  varied  according  to  the  action  of  the  bowels,  which  should 
move  with  it  freely  twice  daily.  This  commonly  acts  also 
somewhat  on  the  urine,  but  the  acetate  of  potassa  may  be 
increased,  and  other  diuretic  ingredients  added,  such  as  sweet 
spirits  of  nitre,  digitalis,  etc.  if  needed.  This  mixture  is  always 
taken  three  times  daily,  fully  half  an  hour  before  eating,  in  one- 
third  tumbler  of  water. 

It  is  interesting  to  note  that  Dr.  Forbes  Ross,1  a  London 
cancer  surgeon,  whose  untimely  death  has  deprived  us  of  a 
valuable  scientific  worker  along  our  present  lines,  was  an  ardent 
advocate  of  potassium  in  the  treatment  of  cancer,  whose  value  he 
established  on  bio-chemical  as  well  as  on  clinical  grounds; 
and  he  is  even  more  positive  in  regard  to  the  actual  control  of 
the  disease  by  potassium  than  the  present  writer  has  cared  to 
express  himself.  He,  however,  pushes  the  administration  of  the 
salt  of  potassium  far,  far  in  excess  of  that  which  I  have  found 
necessary:  this  is  probably  because  he  had  not  yet  reached  the 
point  of  the  influence  of  correct  diet  on  cancer.  Dr.  Ross 
prefers  potassium  citrate  and  potassium  phosphate  combined, 
of  which  he  gives  as  much  as  from  90  to  180  grains  per  day. 
He  has  related  instances  of  advanced,  inoperable  cancer  in 
which  the  results  were  remarkable,  and  one  of  them,  a  case  of 
cancer  of  the  uterus  in  a  widow  aged  59,  was  quite  a  counterpart 
of  one  which  I  shall  report  in  the  final  chapter. 

1  Forbes  Ross,  "Cancer,  the  Problem  of  Its  Genesis  and  Treatment."    Lon- 
don, 1012. 
21 


32  2  CANCER 

Dr.  Ross  had  operated  much  on  cancer,  but,  realizing  the 
inefficiency  of  surgery  to  cure  the  disease,  he  wrote  very  severely 
in  regard  to  cancer  surgery  in  the  opening  chapter  of  his  book. 
After  "ten  years  of  constant  microscopic,  clinical  and  surgical 
research"  he  advanced  the  hypothesis  that  "cancer  is  due  to  a 
want  of  balance  in  particular  mineral  salts  of  the  body,  and  that 
the  disturbance  of  this  balance  leads  to  the  disorderly  and 
malignant  growth  of  epithelial  cells  (epiblastic  and  hypoblastic) 
known  as  carcinoma,"  and  claims  that  the  main  disturbance  is 
in  regard  to  the  potash  balance  in  the  body.  By  very  careful 
deductive  and  inductive  reasoning,  and  by  actual  experimenta- 
tion and  practice,  he  shows  how  this  answers  and  explains 
more  of  the  puzzles  and  intricacies  of  the  cancer  problem  than 
any  other  hypothesis,  and  the  experience  of  many  others  has 
certainly  borne  this  out  in  practice. 

Dr.  Ross  makes  three  references,  which  in  a  measure  support 
the  potassium  theory  of  cancer. 

"i.  The  old  physiological  adage,  'potassium  is  the  salt  of  the 
tissues,  and  sodium  the  salt  of  the  fluids  of  the  body/  still 
holds  good  as  an  absolute  physiological  truth. 

"2.  Animal  physiology  teaches  us  that  the  whole  range  of  the 
animal  creation,  from  an  ameba  to  man,  follows  the  same  law, 
'Potassium  is  the  salt  of  the  tissue  cell.' 

"3.  Examination  of  the  botanical  world  brings  us  face  to 
face  with  the  same  identical  statement,  'Potassium  is  the  salt 
of  the  chemical  physiology  of  the  vegetable  cell.'" 

In  regard  to  the  blood  cells,  Dr.  Ross  shows  the  importance  fo 
potash  in  the  following  language.  "How  vitally  important 
potassium  salts  are  to  the  red  corpuscles  is  shown  by  the  fol- 
lowing: One  thousand  parts  of  red  blood  corpuscles  are  found 
to  contain  688  parts  of  water,  308  parts  of  organic  solids,  and 
8  parts  of  mineral.  Of  these  8  parts  of  mineral  substances 
3.5  are  of  potassium  chlorid,  2.5  are  of  potassium  phosphate, 
and  0.1  potassium  sulphate:  the  remaining  1.9  parts  are 
divided  between  the  iron,  sodium,  calcium,  and  magnesium, 
comprising  the  rest  of  the  corpuscles.  More  than  three-quarters 


MEDICAL  TREATMENT  323 

of  the  total  mineral  ash  of  the  red  corpuscles  is,  therefore, 
composed  of  potassium." 

It  is  not  a  little  satisfactory  to  find  from  a  surgeon  such  a 
microscopic,  bio-chemical,  and  clinical  explanation  and  support 
for  a  line  of  treatment  which  I  have  followed  for  so  very  many 
years,  solely  on  clinical  grounds.    Dr.  Ross  makes  the  interesting 
statement  that,  having  used  enormous  quantities  of  potash 
salts  in  his  practice  for  15  years,  for  various  complaints,  not  one 
single    case    of  cancer  had  ever  to  his  knowledge  occurred 
among  the  clientelle  of  his  own  practice;  he  had,  however, 
constantly  been  engaged  in  operating  on  patients  with  cancer 
sent  to  him  by  other  medical  men.     I  made  much  the  same 
remark  in  regard  to  the  absence  of  cancer  among  my  patients, 
in  one  of  my  lectures,  before  I  had  seen  the  work  of  Dr.  Ross. 
The  first  and  basic  treatment,  therefore,  in  addition  to  dietetic 
and  hygienic  measures,  is  a  full  amount  of  a  potassium  salt,  of 
which  I  prefer  the  acetate  (but  Dr.  Ross  the  citrate,  phosphate, 
and  sometimes  carbonate),  as  previously  mentioned,  in  combin- 
ation with  cascara  and  rumex  fluid  extract.     This  latter,  an 
extract  of  the  yellow  dock  root,  is  one  of  the  old,  so  called  altera- 
tive remedies,  which  I  have  used  for  many  years,  generally  in 
this  combination,  for  certain  skin  diseases.     And  it  was  the  dis- 
appearance of  lumps  in  the  breasts  of  patients,  which  had  been 
diagnosticated  by  surgeons  as  cancer,  while  taking  this  mixture 
for  some  skin  complaint,  that  first  directed  my  attention  to  the 
disease,  very  many  years  ago,  and  led  to  my  adding  cancer 
to  skin  diseases, when  I  founded  the  New  York  Skin  and  Cancer 
Hospital,  about  40  years  ago.     I  have  had  cancer  patients  where 
this  mixture,  with  little  variation,  has  been  taken  for  months, 
or  even  years,  with  occasional  alternation  with  other  remedies 
as  required,  with  most  satisfactory  results. 

But  it  must  not  be  imagined  that  this  is  the  only  line  of  treat- 
ment necessary  in  these  cases,  to  meet  the  different  conditions 
which  may  lead  up  to  the  disturbed  metabolism  of  cancer. 

Patients  with  a  cancer  of  the  breast  just  beginning,  will  often, 
or  even  generally,  seem  to  be  in  excellent  health.     They  are 


324  CANCER 

ruddy  and  blooming  in  appearance,  and  when  the  lump  is  first 
discovered  it  is  hard  indeed  to  believe  that  if  the  erroneous  life 
processes  which  caused  the  cancerous  lesion  to  develop  are  not 
checked,  that  patient  will  before  long  succumb  to  the  direful 
disease.  Williams1  remarks  that:  "Such  types  are  indications 
of  hypernutrition.  Such  cases  show  great  benefit  from  thyroid 
feeding,  and  Bell  reports  many  instances  with  surprising  results 
from  this  remedy,  with  the  entire  disappearance  of  the  tumor, 
in  a  short  time.  I  often  give  the  thyroid  after  eating,  and  also 
at  bedtime,  in  conjunction  with  the  potassium  and  rumex  mix- 
ture, with  good  result.  In  patients  who  are  at  all  obese,  and 
who  as  a  rule  do  very  badly  after  operation,  it  is  always  desirable 
to  reduce  the  flesh  by  thyroid  at  the  beginning  of  the  treatment. 

Williams2  remarks:  "Cancer  patients  usually  are  of  a  coarse 
physical  type.  Those  recently  attacked  never  present  a  cachec- 
tic appearance.  The  small,  ill-nourished  and  over-worked 
women  of  the  type  so  familiar  in  Lancashire  and  other  large 
industrial  centres,  are  seldom  the  victims  of  the  disease.  Of 
75  consecuitive  cases,  when  they  first  came  under  observation 
four  were  markedly  cachectic  or  sallow  (primary  3,  recurrent  1) 
eight  were  emaciated  (primary  6,  recurrent  2)  and  14  pale  (pri- 
mary 10,  recurrent  4) :  the  remaining  49  (primary  39  recurrent 
10)  were  well  nourished  and  healthy  looking,  seven  of  them 
being  obese."  Of  course,  with  cancerous  lesions  affecting  in- 
ternal organs,  and  when  the  carcinosis,  or  cancerous  habit  has 
already  been  under  way  for  some  time  before  medical  observa- 
tion, cachexia  and  loss  of  weight  are  often  prominent  symp- 
toms, as  the  cancerous  lesions  themselves  also  aid  in  disturbing 
the  processes  of  metabolism  and  nutrition,  as  already  explained. 

But  a  most  careful  study  in  every  particular  of  all  patients 
affected  with  cancer,  even  in  very  early  stages,  and  probably 
some  time  before,  will  so  constantly  reveal  such  various  errors 
of  life  and  derangement  of  metabolism  that  these  must  be 
looked  upon  as  contributing  causes,  at  least,  to  the  development 

1  Williams,  "The  Natural  History  of  Cancer."     New  York,  1908. 

2  Williams,  "  A  Monograph  on  Diseases  of  the  Breast."    London,  1894,  p.  286. 


MEDICAL  TREATMENT  325 

of  the  local  condition  which  later  becomes  malignant.  In  the 
same  way  a  patient  will  appear  to  be  in  blooming  health  just 
before  an  attack  of  acute  gout,  but  sufficient  study  and  analysis 
some  time  before  would  reveal  a  condition  of  system  which  an 
experienced  eye  would  recognize  as  a  forerunner  of  the  disease. 
For  when  these  conditions  in  cancer,  whether  early  or  late,  are 
recognized  and  sufficiently  rectified  by  proper  dietetic  and  medi- 
cinal measures,  the  local  cancerous  condition  not  only  ceases 
to  develop  but  actually  disappears,  without  surgical  removal,  as 
I  have  repeatedly  shown:  and  no  one  doubts  but  that  the  threat- 
ening attack  of  gout  could  be  warded  off  in  the  same  manner. 
We  know  what  passes  for  good  health  is  often  fictitious,  and  is 
quite  compatible  with  even  grave  disorders  of  various  kinds. 

It  is  readily,  seen  therefore,  that  no  very  definite  directions 
can  be  given  here  as  to  all  of  the  internal  medicinal  treatment 
of  cancer,  other  than  has  been  already  said.  As  remarked  before 
there  is  no  one  single  remedy,  nor  even  any  single  course  of 
treatment  which  is  to  be  invariably  followed,  or  is  always  suc- 
cessful in  every  case  of  cancer.  Nor  will  there  ever  be  such,  for 
the  palpable  reason  that  the  true  nature  of  cancer,  as  heretofore 
developed,  precludes  the  possibility  of  such  a  thing. 

But  many  articles  in  the  materia  medica  may  very  materially 
assist  at  times  in  overcoming  the  cancerous  state.  Iron  is  very 
often  of  great  service,  when  properly  used,  in  meeting  the  cach- 
exia as  it  develops,  and  of  this  I  prefer  the  dialyzed  iron,  given 
in  pretty  full  doses  in  the  middle  of  the  meal.  Arsenic  with  it 
helps  somewhat,  and  Bell  speaks  very  highly  of  the  hypodermic 
use  of  atoxyl,  every  other  day,  in  addition  to  other  treatment. 
In  certain  cases  I  have  seen  greater  improvement  when  phos- 
phatic  preparations  were  added  or  substituted  for  other  reme- 
dies, as  seemed  indicated  by  the  nerve  condition  of  the  patient. 
And  I  find  nothing  better  than  what  is  known  as  Horsford's  acid 
phosphates,  taken  freely  whenever  needed  for  neurasthenic 
feelings;  and  various  remedies  may  be  needed  to  restore  and 
keep  the  bodily  functions  in  perfect  condition. 

Cancer  is  continually  found  to  be  connected  with  rheumatic 


326  CANCER 

symptoms  of  various  kinds,  and  neuritis,  often  very  severe, 
away  from  the  neighborhood  of  the  local  disease,  is  not  uncom- 
mon; so  that  from  first  to  last  I  may  use  aspirin  very  freely  in 
many  cases,  and  it  seems  to  do  the  local  cancerous  lesion  good 
also.  I  always  give  it  in  powder  form,  in  capsules,  with  hot 
water,  and  have  it  repeated  in  two  hours,  or  as  often  as  necessary. 
This  is  also  my  main  reliance  in  connection  with  the  pain  of  the 
actual  cancerous  lesion,  and  it  is  generally  sufficient,  when  the 
patient  is  under  full  and  efficient  dietetic  hygienic,  and  medicinal 
treatment.  Morphia  is  practically  never  needed  then,  and  it  is 
the  very  rarest  thing  for  me  ever  to  sanction  it,  and  I  have  taken 
it  away  from  very  many  patients,  without  complaint 

A  word  more  in  regard  to  the  bowel  action,  which  should  be 
quite  a  little  more  than  normal.  At  the  beginning  of  treat- 
ment I  very  commonly  give  a  certain  old  pill,  the  supreme 
value  of  which  is  known  to  many,  it  is  as  follows:  R.  Extract, 
colocynth.  comp.,  Massae  hydrargyrii  aa  Gr.  x  Pulv.  Ipecac. 
Gr.  ij — Div.  in  Caps.  No.  iv — take  two  at  night  and  two  on  the 
second  night  after.  In  many  cases,  especially  in  full  blooded 
persons,  I  have  these  repeated  each  week  on  exactly  the  same 
nights,  for  some  weeks,  perhaps,  but  never  more  frequently. 
When  taking  the  mixture  of  acetate  of  potassa  and  rumex,  or 
at  other  times,  I  have  long  found  the  very  best  results  as  to  bowel 
action  secured  by  a  tablet  now  made  by  several  firms,  as  follows: 
R.  Podophyllin,  Cascarin,  Aloin,  each  Hgr.:  from  one  to  three 
four  or  more,  may  be  taken  at  bedtime,  with  excellent  results. 

In  giving  potassa  very  freely  many  fear  a  bad  action  on  the 
heart,  as  the  older  books  say,  but  never  have  I  found  it  to 
be  the  case,  though  of  course,  there  is  not  the  slightest  objec- 
tion to  administering  strophanthus  or  digitalis  at  the  same 
time. 

Mention  was  made  of  the  value  of  thyroid  extract  in  cancer, 
and  some  of  the  other  endocrinous  extracts  have  been  employed 
with  advantage  by  a  number  of  observers,  alone  or  in  combi- 
nation. While  from  my  personal  experience  along  this  line 
I  am  not  in  a  position  to  speak  strongly,  except  in  reference  to 


MEDICAL  TREATMENT  327 

thyroid,  I  cannot  but  believe  that  rightly  used  they  can  have 
a  beneficial  effect  in  cancer.  From  my  reading  and  studying 
I  am  convinced  that  all  of  them  have  some,  almost  mysterious, 
effect  on  the  nutrition  and  behavior  of  the  cells  of  the  body, 
as  mentioned  in  regard  to  myxcedema,  Addison's  disease,  and 
gigantism.  It  is  quite  possible  that  with  a  blood  stream 
vitiated  by  dietary  or  other  errors,  and  wrong  action  of  the 
ordinary  secretory  and  excretory  glands  of  the  body,  the 
endocrinous  glands,  in  common  with  other  structures,  may 
suffer  and  so  be  unable  to  do  their  part,  whatever  that  may  be, 
in  the  balancing  or  equalizing  the  general  metabolistic  powers 
of  the  system.  In  this  case  the  introduction  of  the  normal 
endocrinous  tissue  from  healthly  animals  may  supply  quite  the 
element  wanted  in  the  human  system,  just  as  ox  bile  has  long 
been  of  service  in  medicine,  and  the  effect  of  adrenalin  on 
blood  vessels  is  well  known.  I  think  therefore,  that  the 
evidence  is  very  strong  that  preparations  from  some  of  the 
ductless  glands  of  animals  may  and  probably  will  sometime 
be  an  established  element  in  the  treatment  of  cancer, 
in  conjunction  of  course,  with  diatetic  and  other  proper 
measures. 

The  local  medical  treatment  of  cancer  often  forms  an  impor- 
tant part,  both  in  the  comfort  afforded  the  patient  and  as  a 
measure  of  benefit  to  the  diseased  part. 

In  the  early  stages  of  breast  cancer,  keeping  the  part  painted 
night  and  morning  with  a  mixture  of  equal  parts  of  true, 
imported  ichthyol  and  water  appears  to  help  in  the  disappearance 
of  the  lesion,  as  I  have  observed  in  dozens  of  cases,  and  have 
thought  that  it  aided  in  dispelling  the  darting  pain  common  in 
them.  In  the  late  cutaneous  nodules,  developing  thickly  in 
cases  recurrent  after  operation,  I  have  seen  them  fade  away, 
almost  magically,  under  the  constant  painting  with  thiol  and 
olive  oil  each  50  per  cent,  as  in  one  of  the  cases  to  be  reported 
in  the  final  chapter.  Sometimes  I  have  used  the  tincture  of 
iodine,  with  glycerine,  a  drachm  to  the  ounce,  with  equally 
good  results,  on  unbroken  surfaces  in  early  cancer.    All  of 


328  CANCER 

this  local  treatment  is,  of  course,  in  conjunction  with  complete 
internal  treatment  as  already  indicated,  for  certainly  these,  or 
any  other  local  measure  would  be  powerless  alone. 

In  the  terrible,  ulcerating  surfaces  formed,  especially  in 
recurrent  cancer,  the  very  greatest  relief  and  benefit  is  con- 
tinually seen  when  the  harsh,  surgical  dressing  with  gauze  is 
replaced  by  a  soothing  ointment,  thickly  spread  upon  very 
thin  portions  of  absorbent  cotton,  and  gently  laid  so  as  to  cover 
the  entire  area.  This  may  be  covered  with  gauze  held  in  place 
by  adhesive  strips,  but  I  deprecate  any  thick  mass  of  cotton, 
or  much  bandaging.  The  ointment,  softened  by  a  little  heat 
if  necessary,  is  easily  spread  on  thin  portions  of  absorbent  cot- 
ton, perhaps  3  inches  each  way,  held  on  the  hand  and  applied 
with  a  steel  spatula  or  ordinary  table  knife.  The  joy  and 
relief  experienced,  especially  by  hospital  patients,  when  this 
change  of  dressing  is  made  is  very  gratifying.  The  ointment 
layer  should  be  pretty  thick,  and  so  well  spread  that  the  fibres 
of  cotton  need  not  touch  the  sore.  This  is  generally  changed 
twice  in  the  24  hours  or  oftener  if  desired,  and  being  gently 
removed,  fresh  portions  having  been  prepared  in  advance, 
they  are  quickly  replaced,  without  having  much  exposure  to 
the  air.  I  do  not  have  the  surfaces  treated  much  otherwise, 
except  under  certain  circumstances  to  be  mentioned  later,  but 
if  there  is  much  moisture  or  suppuration  on  removing  the 
dressing,  the  surface  may  very  gently  be  sopped  with  a  bit  of 
dry  absorbent  cotton. 

The  ointment  almost  invariably  used  at  the  hospital,  and 
generally  in  private  practice,  is  that  of  calamine  and  zinc, 
which  I  introduced  many  years  ago,  and  is  now  well  known. 
R.  Acidi  carbolici  9i  Pulv.  calaminas  prep.  3iv.  Zinci  oxidi 
3  ij.  Unguent  aquae  rosae  5iv.  When  there  is  much  pain 
a  drachm  or  more  of  a  4  per  cent  solution  of  cocaine  is  incorpo- 
rated in  the  ointment.  Sometimes  a  few  grains  of  acetate  of 
morphine  in  solution,  worked  into  the  ointment  serves  better. 
It  is  surprising  to  see  how  the  diseased  surface  will  improve 
under  this  method  of  handling,  and  often,  with  all  other  treat- 


MEDICAL  TREATMENT  329 

ment  proper,  evidence  of  normal  epitheliation  will  appear  in 
places  and  increase  steadily. 

A  very  considerable  share  of  the  suppuration  and  pain  in 
cancerous  raw  surfaces  is  undoubtedly  due  to  the  presence  and 
operation  of  the  omnipresent  pus  bacilli,  rather  than  to  the 
disease  itself,  for  it  is  out  of  the  question  to  keep  these  surfaces 
aseptic.  This  may  in  a  measure  be  obviated  by  the  proper 
use  of  antiseptics,  though  they  sometimes  seem  even  to  irritate 
the  sore.  I  have  used  the  peroxide  of  hydrogen,  generally 
with  good  effect,  applied  thus:  pouring  it  out  in  a  saucer,  very 
thin  portions  of  absorbent  cotton  are  very  thoroughly  soaked 
in  it,  and  being  lifted  carefully  are  made  to  lie  over  all  the 
affected  surface.  In  five  minutes  these  are  replaced  by  a 
second  set,  remaining  on  for  five  or  ten  minutes,  and  on  their 
removal  the  portions  of  cotton,  firmly  spread  with  the  calamine 
and  zinc  ointment  are  quickly  laid  on,  without  attempting  to 
dry  the  surface.  Latterly  I  have  been  using  in  the  same 
manner  chinosol,  one  tablet  in  a  pint  of  water  with  half  a 
teaspoonful  of  salt  in  it,  with  good  effect,  possibly  better  than 
with  the  peroxide.  Sometimes  the  chinosol  solution  seems 
a  little  strong,  and  it  may  be  diluted  one-half,  and  then  be 
made  stronger  if  agreeable. 

In  early  cancer  of  the  lip,  under  proper  internal  treatment  I 
have  repeatedly  seen  the  local  lesion  entirely  disappear,  and 
remain  indefinitely  absent,  under  just  the  right  internal  and 
local  management,  as  will  be  reported  in  a  case  or  two  in  the 
final  chapter.  For  this  I  have  an  ointment  quite  thickly 
spread  upon  what  I  call  "a  whiff  of  cotton,"  and  kept  on  all 
the  time,  day  and  night,  even  during  meals,  changing  it  quickly 
several  times  daily.  At  first  this  seems  to  the  patient  difficult 
to  accomplish,  but  it  is  surprising  to  see  how  soon  they  learn 
to  apply  it,  deftly  and  perfectly,  better  than  I  can  myself.  The 
ointment  commonly  used  is  as  follows:  1$.  Ichthyol  (imported) 
3ss-5i  Zinci  oxidi  5i  Unguent  aquas  rosae  5i-  If  the 
hardness  persists  I  often  add  a  trifle,  gr.  v-x  of  well  powdered 
salicylic  acid,  or  pyrogallic  acid  to  the  ounce;  occasionally  if  it 


330  CANCER 

is  at  all  irritated,  the  calamine  and  zinc  ointment,  just  men- 
tioned, may  be  alternated  with  it. 

In  cancerous  lesions  within  the  buccal  cavity  my  constant 
application  for  many  years  has  been  simply  a  saturated  solution 
of  bi-carbonate  of  soda,  diluted  more  or  less  if  it  seems  too 
strong,  but  generally  it  is  not,  used  six  times  a  day,  \i  hr. 
before  and  34  hr.  after  each  meal.  The  idea  of  this  is  to  secure 
an  alkaline  condition  of  the  mouth,  for  the  saliva,  as  before 
remarked  is  invariably  acid  instead  of  alkaline,  and  cancer 
develops  in  an  acid  medium,  as  previously  stated.  The  solu- 
tion is  held  in  the  mouth  for  some  time,  a  few  minutes,  and 
well  worked  around,  with  pressure,  and  repeated  twice  at  each 
application.  The  use  of  it  after  eating  serves  to  cleanse  the 
mouth  of  particles  of  food  which  might  remain  and  induce  an 
acid  fermentation.     The  results  are  excellent. 

In  cancer  of  the  cervix,  I  have  seen,  with  proper  treatment, 
remarkable  results,  as  in  the  cases  to  be  later  reported,  from  a 
simple  but  effective  douche,  which  I  have  long  used  in  very 
many  cases.  It  consists  simply  of  carbolic  acid  and  borax, 
half  to  one  teaspoonful  of  the  former  and  two  to  four  of  the 
latter,  well  dissolved  in  one  pint  of  very  hot  water,  or  as  hot  as 
can  be  borne,  even  up  to  about  no°.  This  is  used  two  or 
three  times  daily,  not  with  an  ordinary  gravity  douche  bag,  but 
with  a  Davison  or  Alpha  ball  syringe.  With  the  long  nozzle 
deeply  inserted,  the  douche  is  squirted  in  with  a  quick  move- 
ment, and  some  force,  against  the  diseased  surface,  and  it  is 
interesting  to  learn  how  soon  the  flow  comes  away  odorless 
and  more  and  more  clear  of  blood  and  pus,  and  finally  quite 
clear.  The  idea,  of  coures,  is  disinfection,  with  a  complete 
alkalinization  of  the  affected  parts,  while  the  heat  and  sharp 
impact  of  the  stream  stimulates  the  diseased  cells  to  healthy 
action.  With  all  this  treatment  cases  of  advanced,  inoperable 
cancer  have  recovered,  and  remained  well  for  years  with  proper 
diet  and  internal  measures. 

In  the  case,  to  be  mentioned,  of  a  sarcoma  of  the  cheek  which 
had  left  a  large  opening,  with  ulcerated  surfaces  within  the 


MEDICAL  TREATMENT  331 

buccal  cavity,  an  extemporized  solution  was  made  up  and  kept 
continually  applied,  renewed  several  times  daily,  with  pledgets 
of  absorbent  cotton,  from  the  beginning  of  treatment,  until  all 
was  healed  and  a  skin  graft  inserted,  which  latter  took  perfectly, 
with  permanent  healing  of  the  opening  and  good  cosmetic  re- 
sults. She  was,  of  course,  under  thorough  internal  treatment 
all  the  while,  and  for  a  long  time  afterwards,  also  she  was  long 
watched.  The  lotion  referred  to  was  as  follows:  Acidi  carbolici 
5ss  Listerine  5i.  Liquor  sodae  chlor  5i-  Glycerine  Sss.  Aqua 
hydrogenii  dioxidiad  5iv  M. 

The  local  treatment  of  epithelomatous  lesions  of  the  skin  by 
#-ray  and  radium  is  considered  in  another  chapter. 

We  have  thus  seen  that  the  medical  treatment  of  cancer  is 
no  trifling  matter,  and  must  be  entered  upon  and  faithfully 
conducted  with  great  patience  and  perseverance,  until  long 
after  the  local  signs  of  the  disease  have  ceased.  How  long  this 
must  be  I  cannot  possibly  tell,  but  the  results  amply  repay  all 
the  work  that  can  possibly  be  put  into  it,  and  a  good  share  of 
patients  are  duly  appreciative  when  they  are  really  made  to 
understand  what  they  have  escaped. 

Early  lesions  can  certainly  be  dissipated  and  the  patient  can, 
I  believe,  surely  remain  well  indefinitely  under  proper  conditions 
of  life,  as  a  number  of  my  breast  cases  were  followed  14  to  16 
years.  In  some  cases  of  stomach  cancer,  so  diagnosticated 
by  every  test,  including  #-ray,  given  by  able  physicians  and 
surgeons,  the  symptoms  all  vanished  and  they  seemed  well, 
but  of  course,  some  patients  where  the  disease  was  advanced 
have  died.  In  a  case  of  apparent  cancer  of  the  second  kidney, 
where  the  removed  one  was  absolutely  cancerous  micro- 
scopically, which  will  be  recorded  later,  the  patient  who  was  in 
a  very  bad  condition  when  first  seen  has  lived  4  years,  weigh- 
ing more  than  ever,  working  very  hard  all  the  time,  and,  so 
far  as  can  be  seen,  perfectly  free  from  his  former  trouble. 
Fuller  statements  will  be  made  in  the  final  chapter. 

The  whole  proper  thought  about  cancer,  therefore,  is  that 


332  CANCER 

the  local  lesions,  which  may  arise  from  discoverable  local  irri- 
tation or  from  some  unknown  reason,  and  may  develop  in  any 
and  probably  every  part  of  the  body,  wherever  epithelial  cells 
exist,  are  all  one  and  the  same  manifestations  of  one  and  the 
same  error  in  nutrition.  This  latter  is  the  culmination  of  long 
standing  modes  of  life  which  have  produced  such  a  condition  of 
the  blood  current  nourishing  the  tissues,  that  some  cells,  under 
peculiar  exciting  circumstances,  have  rebelled  against  the 
physiological  laws  under  which  they  formerly  underwent  the 
normal  changes  of  catabolism  and  anabolism  pursued  by  their 
healthy  and  well  behaved  comrades.  Having  once  started  on 
this  abnormal  course,  and  being  fed  with  the  same  perverted 
blood  stream,  they  naturally  pursue  a  vicious  course  until 
they  receive  again  their  proper  nourishment,  and  are  possibly 
influenced  by  neighboring  regenerated  cells  and  leucocytes. 

The  treatment,  therefore,  is  practically  the  same  for  true 
epithelial  cancer  in  every  location,  for  each  lesion  is  essentially 
the  result  of  the  same  internal  cause,  being  specially  incited  by 
some  local  irritation.  These  vitiated  conditions  of  disordered 
blood  explain  equally  well  the  result  of  metastasis,  whereby 
cells  already  diseased  are  carried  along  until  they  lodge  and 
form  a  new  focus  of  irritation,  which  is  fed  by  the  same  dis- 
ordered blood  stream  until  a  real  palpable  neoplasm  forms  there. 
This  also  explains  why  these  metastatic  lesions  also  disappear 
under  proper  constitutional  treatment,  as  we  constantly  see 
them  do  in  connection  with  breast  cancer,  and  presumably  in 
deeper  metastatases,  as  the  patient  recovers  from  uterine  and 
other  manifestations  of  neoplastic  growth. 

Sarcoma,  which  is  only  a  cancerous  form  of  mesoblastic 
tumor,  as  Forbes  Ross  remarks,  has  repeatedly  been  found  to 
respond  to  the  same  therapeutic  measures. 

The  prophylaxis  of  cancer  naturally  follows  the  same  lines  as 
already  indicated.  How  early  the  tendency  to  the  disease 
carcinosis,  or  cancerous  dyscrasia,  can  be  suspected  and  guarded 
against  remains  to  be  seen.  But  I  have  repeatedly  asserted 
before    medical    assemblies    that    if    the    systemic  conditions 


MEDICAL  TREATMENT  333 

mentioned  were  seriously  guarded  against,  and  the  "green 
card  diet"  had  been  accurately  followed  for  several  years,  and 
persisted  in  indefinitely,  any  one  would  be  insured  against  the 
development  of  cancer.  This  may  seem  a  rash  statement,  but 
long  observation  and  study  have  so  thoroughly  convinced  me  of 
the  correctness  of  the  views  set  forth  in  these  pages  that  I 
feel  warranted  in  making  it.  And  I  am  confirmed  in  my 
judgment  by  the  large  number  of  confirmatory  letters,  which  I 
am  receiving  from  physicians  all  over  the  country,  telling  of 
the  results  they  have  had  from  following  out  this  line  of  treat- 
ment. Time  will  show,  and  it  is  hoped  before  long,  how  far  the 
principles  and  practice  here  indicated  are  correct,  by  a  diminu- 
tion in  the  mortality  reports  of  this  terrible  disease. 


CHAPTER  XVIII 
CLINICAL  CONSIDERATIONS  AND  RESULTS 

In  the  first  small  book,  published  6  years  ago,  on  "  Cancer,  its 
cause  and  treatment,"  I  remarked,  "  The  test  of  everything  lies 
in  the  results  obtained.  Theories,  discussions  and  arguments 
are  unavailing  unless  results  show  their  truth,"  and  eight  cases 
of  undoubted  cancer  of  the  breast  were  then  reported,  four  of 
them  of  particular  interest,  two  of  the  patients  I  had  then  fol- 
lowed for  1 6  years  and  two  for  9  years,  all  of  whom  had  remained 
perfectly  well  without  operation. 

In  the  second  little  book  I  repeated  the  same  sentences, 
saying  that  I  could  then  utter  them  with  stronger  emphasis, 
after  2  years  further  experience  and  an  immense  amount  of 
reading  and  study,  and  I  then  reported  nine  more  illustrative 
cases,  from  among  many  others,  all  showing  remarkable  results, 
some  of  them  dating  back  5  years  or  more.  And  now  after  6 
years  of  specially  active  work  along  these  lines,  added  to  40 
previous  years  of  moderate  devotion  to  this  branch  of  practice, 
I  call  attention  to  the  same  words  with  greatly  increased  interest 
and  certainty,  predicated  upon  daily  experience  with  the  disease 
and  intensive  study  of  literature,  with  more  illustrative  cases, 
making  over  ninety  in  all,  out  of  many  hundred  under  observa- 
tion and  treatment. 

In  the  preceding  chapters  I  have  endeavored  to  present  the 
scientific  basis  for  the  constitutional  nature  and  treatment  of 
cancer,  and  I  may  say  that  to  my  knowledge  these  views 
have  never  been  effectively  refuted,  either  in  discussions  before 
societies  or  in  literature,  while  the  very  many  most  favorable 
book  reviews,  and  innumerable  letters  and  statements  from 
physicians  and  surgeons  endorsing  the  views  and  treatment 
set  forth,  have  been  most  satisfying  and  encouraging. 

334 


CLINICAL  CONSIDERATIONS  AND  RESULTS  335 

Dietetic  and  medical  treatment  of  cancer,  in  the  fullest 
sense,  have  never  yet  been  given  a  fair  and  really  intelligent 
trial  on  a  scale  large  enough  and  long  enough  to  procure  general 
conviction  in  regard  to  their  value;  although  for  many  years 
past  single  physicians  and  surgeons  have  more  or  less  strongly 
advocated  them.  Many  cases  of  cancer  and  sarcoma  have 
been  reported  here  and  there,  which  have  recovered  spontane- 
ously, that  is  without  surgical  interference,  and  often  greatly 
to  the  surprise  of  the  medical  attendant.  This  shows  of  itself, 
that  under  certain  conditions  or  circumstances  something  may 
occur  in  the  system  which  causes  the  malignant  process  to 
cease  and  the  neoplastic  mass  to  subside  and  disappear,  and  the 
cells  to  return  to  their  normal  function.  This  certainly  should 
be  a  stimulus  to  an  endeavor  to  discover  what  the  reason  is  for 
this  beneficial  change,  and  to  seek  to  accomplish  the  same  by 
proper  medical  care.  These  studies  and  measures  have  been 
given  as  far  as  possible  in  what  has  preceded. 

Before  presenting  further  clinical  facts  confirming  the  views 
presented  and  the  treatment  employed,  it  is  but  right  to  state 
that  this  line  of  thought  and  treatment  are  not  of  recent  date, 
and  do  not  represent  any  suddenly  conceived  theory  of  prac- 
tice. They  are  simply  the  growth  of  experience,  dating  back 
over  40  years,  as  previously  mentioned,  to  casual  cases  of  cancer 
of  the  breast,  so  diagnosticated  by  capable  surgeons,  who  had 
urged  immediate  operations,  which  were  not  performed,  and 
which  completely  disappeared  without  surgical  interference, 
under  dietary  and  medical  treatment  given  for  other  complaints. 
The  notes  of  all  these  cases  were  not  kept  in  a  manner  to  be 
used,  but  of  the  eight  cases  reported  in  my  first  book,  the  first 
patient  came  for  treatment  in  1892,  nearly  30  years  ago,  and 
the  second  recorded,  in  1894,  who  were  each  followed  for  16 
years,  as  already  mentioned,  remaining  well,  without  surgical 
interference. 

In  the  third  volume  18  additional  cases  of  malignant  disease 
thus  treated,  from  among  many  more,  were  fully  reported, 
making  35  in  all,  as  samples  of  neo-plastic  disease  which  had 


336  CANCER 

responded  to  medical  treatment  alone  in  a  gratifying  manner; 
this  being  shown  either  by  a  complete  cure  for  years  duration, 
or  by  great  prolongation  of  life  and  amelioration  of  suffering, 
without  the  use  of  an  opiate. 

In  order  to  save  referring  to  those  volumes  and  that  these 
cases  may  help  to  confirm  and  enforce  all  that  has  been  said 
previously,  it  is  but  right  that  their  histories  should  be  again 
recorded  in  abbreviated  form,  before  reporting  some  more, 
from  among  many  others  who  have  come  under  treatment  dur- 
ing the  two  years  since  the  last  publication  or  who  were  held 
over  for  observation  from  former  years. 

The  criticism  has  sometimes  been  made  in  public  and  in 
print,  that  in  the  majority  of  the  cases  the  diagnosis  has  rested 
only  on  clinical  grounds  without  microscopical  proof  of  its 
correctness. 

To  this  may  be  answered:  (i)  That  of  the  post-operative 
cases  there  could  be  no  doubt:  (2)  That  all  are  now  agreed  that 
a  biopsy  in  cancer  is  always  a  very  questionable  procedure,  as 
it  surely  tends  to  spread  the  disease;  and  it  would  be  especially 
perilous  in  such  cases  as  are  to  undergo  medical  treatment,  and 
would  not  be  all  justified,  simply  to  satisfy  so-called  scientific 
curiosity.  (3)  The  vast  majority  of  cancer  operations  in  general 
are  performed  without  microscopical  evidence  as  to  diagnosis. 

(4)  In  almost  every  one  of  the  cases  mentioned,  if  not  in  all, 
there  had  already  been  the  definite  opinion  of  one  or  several 
competent  physicians  and  surgeons,  that  the  disease  was 
cancer,  and  generally  an  immediate  operation  had  been  urged, 
and  in   several  instances  wholly  arranged   for,  but    avoided. 

(5)  Constant  observation  of  and  contact  with  cancer  patients 
for  forty  years  and  more,  in  private  and  public  practice,  should 
warrant  the  present  writer  in  claiming  some  authority  in 
diagnosing  cancer.  (6)  In  regard  to  cancer  of  the  breast  it  is 
claimed  or  stated  by  the  surgeons  that  80  per  cent  of  tumors  in 
that  location,  in  persons  over  30  years  of  age,  other  than  at 
lactation  periods,  either  are  or  certainly  would  be  cancer,  which 
would  be  fatal  within  5  years  if  not  surgically  removed.     The 


CLINICAL  CONSIDERATIONS  AND  RESULTS  337 

soundness  of  this  opinion  may  be  judged  by  the  dozens  of  such 
tumors  which  have  disappeared  and  remained  absent  under 
careful  medical  management  alone. 

In  order  that  a  proper  knowledge  may  be  had  of  what  can 
be  done  by  the  medical  treatment  of  cancer  we  will  first  pre- 
sent abbreviated  reports  of  the  cases  referred  to,  and  then  those 
of  more  recent  cases,  exhibiting  various  points  of  special 
interest. 

Case  I. — Primary  cancer  of  the  breast.  Mrs.  B.  E.  C.  aged 
44,  first  seen  Sept.  19,  1892.  In  the  outer  lower  segment  of 
the  right  breast,  there  was  a  flat,  hard  tumor,  sharply  defined, 
tender  on  pressure,  first  noticed  about  2  months  previously. 
A  well-known  prominent  New  York  surgeon  had  diagnosed 
undoubted  cancer  and  strongly  urged  instant  removal.  Under 
complete  dietary  and  medical  treatment  it  had  entirely 
disappeared  in  6  months.  Four  years  later  she  was  seen 
regarding  the  menopause,  and  the  breast  was  found  perfectly 
normal,  she  still  continuing  the  diet.  The  case  was  followed 
for  16  years  with  no  recurrence  of  the  breast  tumor. 

Case  II. — Primary  cancer  of  the  breast.  Miss  B.  M.  L. 
aged  45,  seen  Jan.  4,  1894.  Tumor  in  the  upper,  outer  quad- 
rant of  the  left  breast,  sharply  defined,  with  some  darting  pains. 
Three  medical  men,  one  a  surgeon  of  prominence,  had  diagnosed 
it  as  cancer,  and  immediate  surgical  removal  had  been  arranged 
for  the  next  day,  but  avoided.  In  2  months  the  lump  was 
recorded  as  less  distinct  and  flatter,  and  within  11  months  it 
had  entirely  disappeared.  A  month  or  two  later  she  had  some 
pain  in  the  breast  in  connection  with  menstrual  disturbance 
accompanying  the  menopause,  but  no  trace  of  the  tumor  could 
be  found.  She  was  seen  at  repeated  intervals  also  for  16  years, 
and  the  breast  was  always  found  perfectly  normal. 

Case  III. — Primary  cancer  of  the  breast.  Miss  J.  M.  A.  aged 
45,  seen  Oct.  12,  1905,  a  hard  working  city  missionary  under 
great  physical  strain,  had  for  some  months  a  tumor  in  the  left 
breast  above  the  nipple,  awaking  her  at  night  with  pain,  with 
also  numb,  shooting  pain  in  the  daytime.     She  had  seen  many 


338  CANCER 

medical  men,  all  diagnosing  cancer,  but  had  declined  the 
operation  urged.  Two  months  later,  December  15,  there  was 
little  to  be  felt  in  the  breast,  and  no  pain,  and  on  Jan.  5,  1906, 
both  breasts  were  the  same,  with  no  sign  of  the  former  tumor. 
She  was  repeatedly  seen  for  9  years  to  the  time  of  reporting, 
being  very  faithful  to  treatment,  and  is  still  in  active  work 
now,  yet  7  years  later,  also  almost  16  years  from  the  first, 
with  no  recurrence  of  the  tumor. 

Case  IV. — Primary  cancer  of  the  breast.  Miss  G.  M.  aged 
44,  a  public  school  teacher,  seen  first  Nov.  13,  1905,  had 
struck  the  breast  in  a  fall,  16  years  before,  but  the  effects  passed 
off  and  there  were  no  sensations  for  7  or  8  years,  when  she  began 
to  have  pain,  aggravated  at  menstruation.  During  the  past 
year  there  was  a  lump  formed  with  constant  pain,  also  pain 
recently  in  the  axilla  which  kept  her  from  school.  A  number 
of  medical  men  had  always  diagnosed  cancer,  and  one,  a  sur- 
geon of  prominence  in  one  of  the  large  hospitals  had  strongly 
pressed  for  an  immediate  operation. 

When  first  seen  there  was  a  tumor,  2  or  3  in.  in  diameter  in 
the  upper  inner  segment  of  the  left  breast,  hard,  sharply  defined 
and  nodular  on  the  surface,  with  enlarged  glands  in  the  axilla. 
She  had  long  been  constipated  and  passed  only  about  60  per 
cent  of  the  amount  of  urinary  solids  proper  for  her  weight. 
Under  very  active  treatment  it  was  recorded,  4  weeks  later, 
that  there  had  been  hardly  any  sensation  in  the  breast  during 
the  previous  week,  that  the  tumor  had  diminished  materially 
in  size  and  hardness,  and  that  she  was  now  out  of  doors  daily, 
feeling  much  better.  One  month  later  it  was  recorded  that  the 
breast  was  about  the  same  as  the  other  but  having  a  little 
caking  and  absolutely  no  pain  for  some  time,  and  she  was  at 
her  duties  in  school.  On  April  7,  it  was  recorded  that  the 
lump  was  all  gone  and  no  glands  could  be  detected  in  the  axilla. 
When  reported  in  19 13,  8  years  later,  she  was  still  free  from 
trouble,  in  spite  of  strenuous  and  often  exhausting  work  as  a 
public  school  teacher.  A  sister  had  recently  died  at  sixty  with 
cancer  of  the  stomach  in  a  distant  country  town.     It  is  now 


CLINICAL  CONSIDERATIONS  AND  RESULTS  339 

over  7  years  still  later,  and  not  long  ago  I  heard  of  her  as  free 
from  her  trouble,  15  years  after  her  first  visit. 

Case  V. — Post-operative  cancer  of  the  breast.  Miss  H.  B. 
aged  61,  June  21,  19 13.  Two  years  previously  a  lump  appeared 
in  the  outer,  lower  segment  of  the  left  breast,  which  was 
removed  in  August,  1911,  healing  soon,  with  a  good  axillary 
scar,  and  remained  well  until  2  months  before  her  visit.  A 
small  red  spot  then  appeared  near  the  sternum  which  en- 
larged and  hardened,  with  others  around  the  scar  until  there 
were  a  dozen,  up  to  half  an  inch  in  diameter,  and  tense  skin 
between,  with  minute  points  developing.  Under  active 
treatment  including  thyroid  and  #-ray,  many  of  the  nodules 
disappeared,  although  some  new  ones  formed  which  were 
removed  surgically,  under  local  anaesthesia,  the  wounds  healing 
kindly.  As  she  lived  some  distance  from  the  city  I  did  not  see 
her  after  Oct.  7,  1914,  as  she  wished  to  take  the  #-ray  nearer 
home,  and  I,  of  course  urged  the  continuance  of  the  dietetic 
and  other  treatment.  In  this  instance  the  patient  lived  com- 
pletely without  pain  and  without  an  opiate  for  almost  16 
months  at  least,  when  otherwise  the  disease  would  have  rapidly 
progressed,  possibly  to  a  fatal  issue  with  the  pain  usual  in 
recurrent  cancer. 

Two  hospital  cases,  recurrent  after  operation,  were  reported 
to  show  the  benefit  that  could  be  given  to  such  in  the  hospital, 
which,  however,  is  not  equal  to  that  obtained  in  private  cases, 
where  every  possible  detail  can  be  effectively  carried  out  by 
intelligent  patients. 

Case  VI. — Post-operative  cancer  of  the  breast.  Mrs.  CM. 
aged  38,  had  an  abscess  of  the  right  breast  19  years  previously, 
which  healed  and  left  a  tumor  the  size  of  a  pigeon's  egg.  This 
remained  quiescent,  until  it  began  to  enlarge,  11  months  be- 
fore removal  surgically,  at  the  New  York  Skin  and  Cancer 
Hospital,  Nov.  14,  191 2,  it  being  then  the  size  of  a  hen's  egg, 
in  the  inner  quadrant.  A  complete  operation  was  then  per- 
formed, with  dissection  of  axillary  and  supra-clavicular  glands, 
and  she  was  discharged  Jan.  16,  1913.     On  Feb.  12,  1914  she 


34©  CANCER 

returned,  in  my  service,  with  an  ulceration  along  the  line  of 
incision  from  the  second  to  the  fourth  rib,  an  inch  or  two 
wide,  with  many  nodules  around,  raised  and  reddened,  quite 
inoperable.  The  liver  extended  2  inches  below  the  edge  of  the 
ribs,  with  a  hard  nodular  margin;  the  right  arm  was  enormously 
swollen,  hard  and  helpless. 

When  she  left  the  hospital,  against  my  wish  June  20,  19 14, 
the  ulceration  had  wholly  healed,  many  of  the  nodules  had 
entirely  disappeared,  the  arm  had  returned  to  the  normal 
size  of  the  other,  as  measured  by  several  in  the  hospital,  and  the 
liver  had  retracted  to  only  a  trifle  below  the  margin  of  the 
ribs,  with  hardly  any  nodular  margin.  All  this  had  occurred 
within  about  5^  months,  under  very  disadvantageous  cir- 
cumstances, for  she  was  a  very  ignorant  Polish  woman  who 
often  rebelled  at  the  diet,  and  wearied  of  the  routine  and  the 
restrictions  imposed. 

The  patient,  who  attracted  a  good  deal  of  attention  in  the 
hospital,  was  subjected  to  careful  investigations  according  to  a 
definite  schedule.  The  blood  studied  weekly  showed  3,262,000 
erythrocytes  on  entering,  which  rose  within  2  months  to  4,282,- 
000;  the  leucocytes  were  9,000  on  entering  and  5,200  before 
leaving,  the  polynuclear  being  69  per  cent,  fell  to  60,  etc. 
The  urine,  volumetrically  analyzed  every  3  days,  was  kept  free 
and  a  little  below  normal  acidity,  with  rather  low  specific 
gravity,  etc.  The  saliva,  tested  and  recorded  Y/±  hr.  before  and 
after  each  meal,  was  acid  at  first  but  became  neutral  and  alka- 
line. The  weight,  taken  weekly,  fell  a  little  from  the  first  as 
desired,  but  maintained  a  good  level  and  rose  before  she  left 
the  hospital,  cured  as  she  supposed. 

One  other,  a  hospital  out-patient,  was  also  reported  on, 
where  the  disease  was  recurrent  after  three  operations,  who  in 
2^  months  showed  a  change  which  was  remarkable  compared 
with  the  increasing  development  of  the  disease  in  the  two 
months  previous. 

Case  VII. — Post-operative  cancer  of  the  breast.  Mrs.  W.  C. 
aged  45,  a  hospital  out-patient,  seen  first  at  my  medical  clinic 


CLINICAL  CONSIDERATIONS  AND  RESULTS  341 

for  cancer,  on  Sept.  17,  19 14.  Nearly  4  years  previously 
a  lump  appeared  in  the  left  breast,  which  was  removed  Jan. 
6,  191 1.  It  soon  regrew  and  a  complete  operation  was 
performed  at  the  New  York  Skin  and  Cancer  Hospital,  May 
30,  191 1.  Two  years  later  there  was  a  return,  and  she  was 
again  operated  on  at  the  hospital,  May  30,  1914.  About  3 
months  later,  2  months  before  her  visit,  there  came  a  swelling 
on  the  sternum,  and  soon  another  above  it,  both  of  which 
increased  rapidly.  When  seen  there  was  a  hard  mass  in  the 
scar  over  the  sternum  about  1}^  in.  long,  raised,  reddened,  and 
immovable,  and  another  smaller,  an  inch  or  so  above,  which 
gave  her  pain  when  at  housework. 

Under  active  treatment  there  was  immediate  improvement, 
and  when  last  seen,  December  7,  both  lumps  had  subsided 
fully  one-half,  there  was  no  pain  at  any  time,  and  her  general 
condition  was  immensely  improved,  she  feeling  better  than  she 
did  4  or  5  years  ago,  that  is,  before  the  beginning  of  the  cancer- 
ous development.  She  had  been  working  all  the  time,  unusually 
hard,  as  janitor  of  four  buildings,  and  also  going  out  scrubbing 
and  working.  She  weighed  157H  lb-  at  first,  ran  down  to  154, 
and  gained  to  155^  at  the  last  visit,  when  she  was  lost  sight  of, 
like  so  many  others.  It  is  often  hard  indeed  to  keep  patients 
faithful  to  the  monotony  of  medical  treatment,  when  the  minds 
of  all  are  so  attracted  by  the  glamor  of  surgery,  and  its 
spectacular  features. 

A  fatal  case  was  reported  to  show  the  benefits  which  can 
be  obtained  even  when  a  primary  case  has  advanced  far 
beyond  the  possible  aid  of  surgery. 

Case  VIII. — Primary,  far  advanced  cancer  of  the  breast. 
Mrs.  M.  B.  J.  widow,  aged  68,  a  private  patient,  was  first  seen 
Feb.  17,  1914.  Two  years  previously  she  had  noticed  a  lump 
in  the  upper  part  of  the  right  breast,  after  great  and  repeated 
mental  distress,  from  the  death  of  a  number  of  very  near  rela- 
tives and  a  sister's  mental  derangement,  the  great  nervous 
strain  having  been  attended  with  various  bilious  attacks,  and 
nervous  indigestion.     The  mass  increased  steadily  in  size  and 


342  CANCER 

was  kept  concealed  even  from  her  family,  until  the  day  before  she 
called,  when  her  family  physician  who  was  consulted  saw  that 
it  was  far  beyond  the  possible  hope  from  any  operation,  in 
which  view  a  prominent  surgeon  concurred. 

When  first  seen  the  whole  breast  was  involved,  double  the 
size  of  the  other,  like  a  very  large  half  melon,  hard  and  immov- 
able. There  was  a  rather  thick  crust,  several  inches  in 
diameter,  adhering  to  an  ulcerating  surface,  beneath  which 
came  a  moderate  discharge.  The  axillary  glands  were  enormously 
enlarged,  and  also  the  supra-clavicular,  and  she  was  strongly 
cachetic.  She  was  placed  under  very  complete  dietetic  and 
medical  treatment,  and  the  breast  kept  painted  with  50  per 
cent  ichthyol  in  water,  the  adherent  crust  not  being  disturbed. 
In  a  very  short  time  the  discharge  ceased,  the  protective  crust 
adhering  until  she  passed  away  peacefully,  from  exhaustion 
and  pulmonary  oedema,  on  Sept.  9,  1914.  On  August  5  it  was 
recorded  that  the  breast  had  done  very  well,  was  soft  and 
movable,  and  not  larger  than  the  other  breast,  with  no  discharge, 
and  no  pain  since  a  short  time  after  beginning  treatment.  The 
axillary  glands  had  diminished  three-quarters  in  size,  and  the 
supra-clavicular  glands  were  also  very  much  smaller.  She 
never  took,  or  required  a  particle  of  morphine  or  any  opiate. 
The  peace  and  comfort  experienced  by  this  lady  during  7 
months  with  an  enormous  inoperable  cancer  and  great  cachexia 
when  first  seen,  was  certainly  very  different  from  the  generally 
conceived  and  observed  course  of  cancer. 

In  the  second  volume  nine  additional  cases  were  recorded, 
which  may  be  synoptized  and  reported  on. 

Case  IX. — Primary  cancer  of  the  breast.  Miss  T.  M.  M.  aged 
37,  consulted  me  Mar.  23,  1916,  for  a  mass  in  the  left  breast, 
which  a  surgeon  of  great  eminence  had  diagnosed  as  cancer, 
urging  most  strenuously  an  immediate  operation,  saying  that 
from  its  rapid  development  she  would  die  within  6  months  if 
not  operated  on.  She  had  had  a  neurasthenic  breakdown  the 
previous  autumn  and  for  some  months  now  had  been  under 
very  great  nervous  strain  with  a  father  aged  71,  slowly  dying  of 


CLINICAL  CONSIDERATIONS  AND  RESULTS  343 

Bright's  disease.  Two  years  ago  she  had  suffered  severely  with 
uricacidsemia. 

The  lump  in  the  outer  upper,  inner  quadrant  of  the  left  breast 
was  noticed  only  a  month  or  two  before  her  visit,  and  had 
increased  rapidly.  When  first  seen  there  was  a  mass  about  2 
inches  in  diameter,  attached  to  the  puckered  skin  over  an  area  of 
1  inch,  and  there  was  considerable  pain,  increased  measurably 
by  the  rather  hard  handling  of  the  surgeon  just  referred  to. 
There  were  a  number  of  enlarged,  hard  axillary  glands. 

Under  very  active  treatment  with  constant  observation  every 
week  or  two,  in  8  months  the  improvement  in  her  general  condi- 
tion and  the  breast  tumor  was  very  marked.  When  she  then 
kindly  appeared  at  my  lecture  at  the  hospital  she  said  that 
she  "felt  a  thousand  times  better."  Her  color  was  excellent, 
she  had  held  her  weight,  153  lb.,  a  trifle  above  that  called  for 
by  her  height  and  age,  and  all  this  in  spite  of  heavy  daily  office 
work  and  very  great  trouble  and  anxiety  nursing  her  father  for 
for  13  weeks,  who  died  in  October 

The  breast  then  was  soft,  with  still  a  lump,  hardly  half  the 
original  size,  the  area  of  attached  skin  had  decreased,  with 
only  a  slight  pimpling  and  the  enlarged  axillary  glands  had 
disappeared.  She  went  on  a  trip  to  Chicago  by  auto,  slept 
perfectly  and  had  no  pain.  Ten  months  after  her  visit  she  had 
a  very  severe  attack  of  grippe,  being  in  bed  3  weeks  in  another 
city,  and  this  with  many  weeks  of  neglect  of  treatment  set  her 
back  a  little  and  she  was  lost  sight  of,  14  months  after  she  had 
been  given  but  6  months  to  live  by  the  surgeon,  she  being 
healthy  and  happy  all  the  time,  and  never  missing  a  day's 
work. 

Case  X. — Primary  cancer  of  the  breast.  Mrs  J.  T.  T.  a  farmer's 
wife,  aged  38,  seen  Aug.  11,  1914.  She  had  been  confined 
with  her  first  child  4  months  previously,  but  had  not  nursed  the 
baby,  and  had  no  trouble  with  the  breast.  Four  weeks  before 
her  visit  she  noticed  a  tumor  in  the  upper,  outer  segment  of  the 
left  breast,  increasing  steadily,  with  considerable  pain.  There 
was  a  mass  the  size  of  an  egg,  hard  and  well  defined,  tender  on 


344  CANCER 

manipulation  with  some  enlarged  axillary  glands.  Under  very 
active  treatment  including  thyroid  and  iron  and  50  per  cent 
ichthyol  locally,  with  Hebra's  diachylon  ointment  later,  the 
lump  disappeared  slowly,  and  just  a  year  subsequently  it  was 
recorded  that  the  breast  was  perfectly  normal  with  no  trace 
of  the  tumor  nor  axillary  adenopathy.  She  was  again  con- 
fined of  a  healthy  child  June,  1916,  and  the  surgeon  who  had 
made  the  orignal  diagnosis  of  cancer  and  urged  immediate 
operation,  reported  the  breast  perfectly  normal.  Seen  and 
examined  very  recently  she  still  remains  free  from  trouble 
over  7  years  after  her  first  visit. 

Case  XI. — Primary  cancer  of  the  breast.  Mrs.  I.  T.  G.  aged 
43,  first  noticed  a  lump  in  the  left  breast  2  weeks  before  her 
first  visit  May  7,  1905.  This  had  been  diagnosed  as  cancer  by 
at  least  four  medical  men,  one  of  them  a  prominent  surgeon  in 
Hartford,  who  urged  immediate  operation.  When  first  seen 
there  was  a  hard,  sharply  defined  mass,  i}4  inches  in  diameter, 
which  gave  a  darting  pain  at  times  and  was  painful  on  light 
handling.  With  vigorous  treatment  the  change  in  the  tumor 
was  remarkable,  and  at  the  end  of  8  weeks  it  was  recorded  that 
there  was  no  trace  of  tumor,  that  both  breasts  were  alike.  She 
was  a  large  flabby  woman,  weighing  207^  pounds,  of  the  kind 
that  do  so  badly  after  operation.  With  absolute  faithfulness 
to  treatment  she  weighed  199  pounds  2  years  later,  with  no  re- 
turn of  the  breast  trouble.  She  was  last  seen  for  another 
difficulty  5^  years  after  her  first  visit,  and  the  breast  was 
found  perfectly  normal. 

Some  cases  of  post-operative  cancer  were  reported  which 
showed  the  stricking  benefit  of  proper  medical  treatment.  But 
it  would  be  unreasonable  to  expect  any  startling  effects  in 
patients  who  had  become  thoroughly  saturated  with  the  poison- 
ous hormone  generated  by  repeated  new  developments  of  can- 
cerous tissue,  and  when  there  were  numerous  metastases,  not 
only  in  internal  organs  and  lymphatic  glands,  but  also  with 
cutaneous  nodules,  produced  in  various  parts  of  the  skin  through 
capillary  infection.     And  yet  in  most  of  the  cases  there  has  been 


CLINICAL  CONSIDERATIONS  AND  RESULTS  345 

a  betterment  of  condition  as  to  color,  weight  and  so  forth,  which 
sometimes  seemed  to  encourage  one  that  the  real  disease  would 
be  conquered.  But  although  life  has  frequently  been  prolonged 
far  beyond  what  might  have  been  expected,  and  discomfort  and 
distress  have  often  been  greatly  lessened  or  entirely  abrogated, 
without  a  particle  of  morphine  or  opiate,  we  have  not  yet 
reached  the  position  of  checking  and  curing  far  advanced  cancer, 
to  a  degree  at  all  comparable  with  what  can  be  accomplished  in 
its  early  stages;  the  benefit  of  this  line  of  treatment,  however, 
was  strikingly  seen  in  the  following  case,  recurrent  after  four 
operations. 

Case  XII. — Recurrent  cancer  of  the  breast.  Mrs.  D.  S.  aged 
53,  first  seen  July  6,  1916,  in  private  practice.  Over  5  years 
previously,  a  small  pimple  as  she  called  it,  appeared  on  the  left 
side  which  was  left  alone  until  Jan.  21,  19 14,  when  the  left 
breast  was  removed  by  a  surgeon  of  prominence  and  all  seemed 
well  for  6  months.  There  was  then  some  return  and  a  second 
operation  was  performed  in  January,  1915.  There  was  again  a 
return,  and  a  third  removal  was  done  in  April,  and  a  fourth 
operation  by  the  same  excellent  surgeon  in  August,  19 15,  but 
the  wound  had  never  healed  since.  There  had  never  been  any 
attempt  at  dieting  or  medical  treatment,  or  any  effort  to  check 
the  cause  producing  the  malignant  growth. 

Since  January,  1916  many  cutaneous  nodules  developed 
around  the  open  area,  which  when  first  seen  presented  a  charac- 
teristic ulceration  8  inches  long  by  two  or  three  wide.  The  axil- 
lary glands  were  enlarged  and  the  left  arm,  which  had  been 
greatly  swollen  since  the  first  operation  was  hard,  tense,  and 
painful,  and  of  course  helpless.  Her  weight  which  had  been 
168  pounds  3  years  previously  was  reduced  to  132.  She  was 
always  constipated  and  the  urine  deficient  and  irritating  and 
frequent  at  night.  She  has  long  suffered  from  rheumatism  and 
also  severe  headaches  up  to  the  menopause,  7  years  before 
her  visit. 

Under  rigid  treatment  she  began  to  improve  much  in  her 
general  feelings,  the  arm  became  soft  and  somewhat  flabby  and 


346  CANCER 

the  nodules  which  had  been  painted  with  50  per  cent  ichthyol, 
were  less  prominent.  The  urine,  which  at  first  was  only  26  oz. 
in  24  hours,  with  great  deficiency  in  solids,  was  brought  up  to  45 
oz.,  with  the  proportion  of  solids  to  her  weight  about  right. 
The  saliva  which  was  very  acid  became  less  so,  though  still  acid 
and  scanty  and  the  mouth  dry.  After  about  5  months  I  find 
a  record  that  she  felt  so  very  well  that  her  friends  think  that 
there  can  not  be  much  the  matter  with  her.  There  was  still 
considerable  ulcerating  surface,  but  painless  and  with  some 
islands  of  healing;  there  were  still  metastatic  nodules  in  the 
skin,  though  fewer,  and  the  arm,  though  still  swollen,  was  useful, 
smaller  and  no  longer  tense,  the  flesh  shaking  when  the  arm  was 
moved. 

The  difference  between  her  condition  and  what  she  would 
have  been  without  treatment  can  hardly  be  imagined,  for  within 
those  5  months  she  would  probably  have  been  in  her  grave, 
whereas  during  all  this  time  she  traveled  back  and  forth  from 
her  home  some  distance  away  in  New  Jersey,  to  my  office,  a 
happy  woman,  without  pain.  Of  course  she  never  took  any 
opiate.  About  this  time  she  fell  and  broke  her  hip,  and  after  some 
months  I  was  asked  to  go  out  and  see  her,  and  found  that  the 
neglect  of  treatment  had  allowed  the  disease  to  assert  itself,  and 
she  was  in  a  poor  condition  and  I  think  she  died  some  weeks 
later. 

Case  XIII. — Post-operative  cancer  of  the  breast.  Mrs.  P.  A. 
aged  46,  a  Bohemian  woman  came  to  my  medical  clinic  at  the 
hospital  July  26,  1916.  She  had  noticed  a  lump  in  her  left 
breast  only  2  weeks  before  it  was  removed  in  the  New  York  Skin 
and  Cancer  Hospital,  2  years  prior  to  her  visit.  Three  months 
later  the  right  breast  was  also  removed  on  account  of  a  lump 
there.  All  seemed  to  go  well  until  about  a  year  later  when 
cutaneous  nodules  appeared  on  the  chest,  around  the  scar  of  the 
former  operation,  which  nodules  increased  in  number  and  size, 
until  when  first  seen  there  were  fully  fifty  of  them,  forming  a 
veritable  cancer  en  cuirasse. 

Under  active  treatment  with  thiol  in  olive  oil  50  per  cent, 


CLINICAL  CONSIDERATIONS  AND  RESULTS  347 

painted  on  night  and  morning,  she  improved  at  once.  Later 
some  of  the  nodules  ulcerated  but  healed  shortly  when  treated 
with  thorium  paste,  diluted  25  per  cent,  so  that  when  shown  at 
my  lecture  something  over  4  months  later,  on  passing  the  hand 
over  the  surface  there  was  hardly  a  trace  of  the  nodules  which 
were  once  so  abundant.  All  who  know  anything  about  the 
ravages  of  cancer  will  realize  the  difference  between  her  condi- 
tion then  and  what  it  would  have  been  under  ordinary  circum- 
stances. She  had  no  pain  after  beginning  treatment  and  no 
opiate. 

Case  XIV. — Inoperable  cancer  of  the  breast.  Miss  J.  M. 
aged  53  was  transferred  to  my  medical  service  in  the  ward  of  the 
New  York  Skin  and  Cancer  Hospital  Aug.  26,  1914,  as  quite 
inoperable.  One  year  before  there  occurred  an  enlargement  of 
the  right  breast  with  general  hardness,  which  broke  down  9 
months  later.  There  was  some  pain  from  the  beginning  which 
became  severe  and  constant.  When  first  seen  there  was  a  great 
fungous  mass,  about  6  in.  in  each  diameter,  with  a  profuse  and 
very  offensive  discharge;  she  was  very  weak,  with  a  septic  tem- 
perature of  1010  and  over,  and  complained  greatly  of  pain,  for 
which  she  was  under  morphine;  there  had  been  no  operation. 

For  a  while  under  active  dietary  and  medicinal  treatment  of 
various  kinds  she  seemed  to  do  remarkably  well,  the  color  and 
weight  improving,  with  less  pain  and  very  comfortable  nights, 
without  any  morphine  or  hypnotic,  which  she  had  previously 
been  taking.  Shortly  her  weight,  which  was  106^  lb.  at  first, 
rose  to  1 10^  lb.  and  October  28th  it  had  risen  to  m^  lb-  By 
October  10th  the  wound  was  secreting  very  little,  she  slept  well 
with  no  opiate,  and  complained  little  of  pain  day  or  night,  and  it 
seemed  as  if  the  disease  was  being  overcome,  as  there  was  some 
evidence  of  cicatrization  in  places.  But  she  then  had  several 
severe  hemorrhages,  and  the  hemoglobin  which  had  been  80 
dropped  to  60  and  the  red  corpuscles  to  2,100,000.  She  rallied 
however,  under  an  intravenous  saline  injection  and  the  Murphy 
drip,  with  proper  medication,  so  that  the  hemoglobin  rose  to  75 
per  cent  and  the  red  corpuscles  were  actually  4,110,000.     But 


348  CANTER 

kidney  trouble  set  in,  and  with  ups  and  downs  she  finally 
succumbed  on  July  3,  19 15,  about  a  year  after  entering  the 
hospital. 

The  case  was  watched  with  great  interest  by  the  attending 
staff,  and  careful  studies  of  the  blood  and  volumetric  analyess 
of  the  urine  were  made  weekly.  The  urine  was  generally  scanty, 
running  even  as  low  as  9  ounces  a  day,  of  fair  specific  gravity 
and  it  was  very  hard  to  raise  the  total  solid  urinary  output  to 
anywhere  near  the  normal  standard.  The  saliva,  tested  and 
recorded  }±  hour  before  and  after  each  meal,  was  commonly 
acid,  often  strongly  so,  though  at  periods  it  would  be  neutral, 
and  occasionally  become  alkaline  for  a  while  under  active  treat- 
ment. The  case  was  an  interesting  one,  but  hopeless  from  the 
first,  and  any  other,  end  could  hardly  be  expected.  But  certainly 
life  was  prolonged  and  much  comfort  secured  as  to  sleep,  almost 
total  abolition  of  pain,  without  morphine,  and  diminution  of 
the  offensive  discharge,  etc. 

Two  cases  of  cancer  of  the  uterus  were  reported  which  were 
of  great  interest  as  they  were  entirely  inoperable  and  have 
remained  well  a  long  time. 

Case  XV. — Inoperable  cancer  of  the  uterus.  Mrs.  F.  L.  A. 
aged  48,  seen  first  on  Mar.  21,  1916,  had  had  four  children 
22,  20,  17  and  12  years  of  age,  also  a  miscarriage  9  years  previous, 
and  the  menopause  had  occurred  suddenly  2  years  before.  She 
had  never  had  trouble  with  confinements  and  never  laceration. 
On  February  24  a  few  drops  of  bright  blood  appeared,  and  she 
was  seen  that  afternoon  by  a  competent  surgeon  in  a  distant 
city,  who  sent  her  to  me;  he  had  found  an  inoperable  cancer 
of  great  extent,  which  diagnosis  was  confirmed  by  others, 
who  refused  to  operate.  The  accompanying  pathological 
report  read  "About  one-third  of  cervix  destroyed,  vaginal 
wall  involved,  right  broad  ligament  infiltrated,  curettings 
revealed  squamous-cell  carcinoma  in  numerous  slides.  From 
histological  appearance  I  judge  that  the  cancerous  process  is 
developing  rapidly."  The  slides  brought  to  me  were  submitted 
to  Dr.  H.  H.  Janeway  who  confirmed  them  to  be  "rapidly 


CLINICAL  CONSIDERATIONS  AND  RESULTS  349 

growing,  malignant  epithelioma."  Those  who  saw  the  patient 
on  February  24  gave  the  opinion  that  she  would  hardly  live 
6  months. 

On  June  2,  not  3  months  after  her  first  visit  she  was  again 
examined  by  Dr.  Janeway  who  reported  "  I  find  no  ulceration 
whatever  on  the  cervix  or  vagina,  the  uterus  is  movable  and  of 
normal  size.  There  are  no  evidences  of  any  disease  remaining 
which  can  be  detected  by  examination."  On  July  7  he  wrote 
"I  have  examined  Mrs.  F.  L.  A.  again  and  find  that  there  has 
been  no  return  of  the  evidence  of  the  disease."  On  October 
20  he  wrote  "Mrs.  F.  L.  A.  appears  to  be  absolutely  free  from 
disease."  This  was  confirmed  by  her  own  surgeon.  It  is  now 
at  the  present  writing  almost  5  years  since  I  first  saw  her,  when 
she  was  given  hardly  6  months  to  live.  A  very  recent  letter 
dated  Feb.  14,  1921  states  that  she  "still  enjoys  the  best  of 
health,"  5  years,  less  10  days,  from  Feb.  24,  1916,  when  she 
was  given  hardly  6  months  to  live  by  several  competent  sur- 
geons and  a  good  pathologist.  There  is  no  reason  to  believe 
that  she  will  not  remain  so,  as  she  is  an  intelligent  and  most 
faithful  patient.  When  last  seen  she  weighed  no  lb.,  her 
normal  weight  before  her  sickness  was  always  93  lb.  During 
the  treatment  she  traveled  back  and  forth  from  Bangor, 
Maine,  repeatedly  without  fatigue. 

The  medical  treatment  and  voluminous  notes  can  hardly 
be  compressed  here,  but  from  first  to  last  she  has  used  the 
douche  of  carbolic  acid  and  biborate  of  soda,  as  described  in 
the  previous  chapter,  with,  of  course,  complete  dietetic  and 
varied  medical  treatment  and  one  application  of  radium,  300 
millicuries,  for  16  hr.  On  March  25  about  4  months  after 
beginning  treatment  her  hemoglobin  showed  80  per  cent  and 
red  blood  cells  4,500,000,  leucocytes  5,800,  of  which  poly- 
nuclears  64,  lymphocytes  27,  transitional  8,  and  eosinophiles 
1  per  cent,  and  she  was  apparently  as  healthy  a  woman  as 
is  often  seen.  I  realize  that  all  this  seems  almost  incredible, 
but  it  can  be  easily  verified  by  her  own  surgeon  and  by  many 
witnesses. 


350  CANCER 

Case  XVI. — Inoperable  cancer  of  the  uterus.  Mrs.  H.  F.  J. 
aged  52  first  seen  Aug.  3,  1916.  This  was  a  very  similar  case, 
also  sent  from  Bangor,  Maine.  She  had  three  children,  27,  25 
and  16  years  of  age.  The  menses  had  been  regular  up  to 
April  15,  then  nothing  to  July  1,  when  there  was  a  clotted 
flow,  checked  by  treatment,  which  had  returned  in  2  weeks 
with  pain,  after  an  auto  ride.  On  July  14  she  was  examined 
by  two  surgeons  who  found  inoperable  cancer  of  the  cervix, 
which  was  confirmed  by  Dr.  Janeway  on  July  31,  who  reported 
"  cancer  of  the  cervix  and  vaginal  canal  with  some  cauliflower 
excrescence."  She  received  one  application  of  radium  300 
millicuries  to  the  canal  and  120  to  the  cervix  for  12  hours. 

Not  to  dwell  long  on  the  case,  under  rigid  dietetic  and  medical 
treatment  and  morning  and  night  douches  as  in  the  other  case, 
she  improved  every  day  and  on  September  30  reported  as 
quite  herself  again.  On  October  20  Dr.  Janeway  reported 
that  Mrs.  H.  F.  J.  was  free  from  disease,  although  the  healing 
was  not  quite  complete,  and  reports  from  her  friends  2  or  3 
years  later  state  that  she  seems  perfectly  well. 

A  remarkable  case  of  sarcoma  was  recorded,  which  yielded 
to  pretty  much  the  same  fine  of  dietetic  and  medical  treatment, 
and  was  followed  for  fully  3  years  after,  remaining  well,  with  a 
perfect  skin  graft  covering  the  operative  deformity. 

Case  XVII. — Post-operative  sarcoma  of  the  jaw.  Miss  R.  L. 
aged  19,  entered  my  service  in  the  New  York  Skin  and  Cancer 
Hospital  July  24,  1916  weighing  89M  lb.,  she  had  formerly 
weighed  120.  The  story  as  given  in  volume  II  is  a  long  one  and 
difficult  to  abstract. 

Three  years  previously  a  small  lump  appeared  beneath  a 
pigmented  mole,  which  had  long  existed,  an  inch  or  so  below 
the  right  eye,  and  grew  until  about  an  inch  in  diameter,  mov- 
able and  painless.  She  had  been  submitted  to  various  surgical 
measures,  and  radium  had  been  used  for  18  hours  on  March  1, 
which  seemed  to  light  up  the  trouble  terribly.  Finally  an 
extensive  operation  was  performed  in  another  hospital,  in 
which  the  right  upper  maxilla  was  removed,  together  with  the 


CLINICAL  CONSIDERATIONS  AND  RESULTS  351 

tumor,  all  of  which  healed.  Four  weeks  before  being  seen  a 
pin-hole  opening  formed  in  the  cicatrix,  which  increased  rapidly 
in  size  until  admission.  The  microscopic  examination  of  the 
portions  removed  at  the  operation  showed  the  disease  to  be 
sarcoma. 

On  entering  the  hospital  there  was  an  opening  in  the  right 
cheek  something  over  an  inch  in  diameter  with  ulcerated  edges, 
and  a  mass  of  ulceration  within  giving  forth  a  foul  odor;  from 
the  upper  margin  of  the  opening  there  was  a  mass  of  dead 
bone  of  the  zygoma  hanging.  She  was  thin,  pale,  and  cachectic, 
with  85  per  cent  hemoglobin  and  3,620,000  red  corpuscles. 
She  was  placed  on  the  same  dietary  and  medical  treatment 
as  the  carcinomatous  cases,  and  the  frequent  use  of  the  wash 
mentioned  in  the  previous  chapter,  kept  continuously  applied 
on  pledgets  of  absorbent  cotton,  renewed  frequently.  The 
change  in  her  general  and  local  condition  from  the  first  was 
something  remarkable.  The  discharge  and  foul  odor  from  the 
ulceration  ceased  shortly,  and  within  a  few  weeks  the  cavity 
and  edges  of  the  opening  showed  a  healthy  condition,  with 
evidence  of  cicatrization. 

To  be  brief,  she  gained  daily  from  the  first  visit,  even  several 
pounds  in  some  weeks,  being  weighed  every  week  in  the  same 
wrapper  by  several  doctors  and  nurses,  who  also  took  great 
interest  in  the  case.  Finally  I  weighed  her  myself  at  130 
pounds  which  was  over  that  called  for  by  her  height  and  age, 
and  10  pounds  more  than  she  had  ever  weighed  before,  and  a 
contrast  to  the  8oJ-£  pounds  which  she  weighed  when  first  seen. 

The  blood,  which  was  carefully  studied  weekly,  steadily 
improved,  until  on  September  18  the  hemoglobin  stood  at  95 
per  cent  with  4,600,000  red  corpuscles  and  8,000  white,  and 
on  November  10  the  hemoglobin  was  100  per  cent,  and  the 
erythrocytes  4,700,000.  On  November  14  all  evidence  of  the 
disease  had  so  completely  gone,  and  the  edges  of  the  opening 
were  so  perfectly  cicatrized,  that  Dr.  Semken  prepared  a  thick 
flap  on  the  arm,  the  raw  surface  of  which  he  lined  with  a 
Thiersch  graft,  and  on  November  24  he  attached  this  over  the 


352  CANCER 

opening,  after  scarifying  its  cicatrized  edges.  Every  stitch 
took  perfectly  and  I  showed  her  at  my  lecture  with  excellent 
cosmetic  results.  She  was  watched  for  a  couple  of  years  when 
she  ceased  coming  to  the  clinic,  but  she  kept  well  in  every  way, 
the  skin-graft  remaining  perfect. 

In  the  next  volume,  "The  Medical  Treatment  of  Cancer," 
1 8  more  cases  were  reported,  which  may  be  more  or  less  fully 
quoted. 

Case  XVIII. — Primary  cancer  of  the  breast.  Mrs.  S.  J. 
aged  33,  first  noticed  a  lump  in  the  right  breast  2  months 
previous  to  her  visit  at  my  hospital  clinic,  Feb.  28,  191 7. 
This  steadily  increased  in  size  until  seen,  when  it  was  fully 
an  inch  and  a  half  in  either  direction,  in  about  the  middle  line 
above  the  nipple,  with  sharp  rather  hard  edges,  and  a  small 
palpable  gland  in  the  axilla;  she  had  been  having  sharp  pains, 
radiating  from  the  breast  to  the  axilla.  For  future  reference 
I  called  in  the  surgeon  in  attendance,  who  at  once  recognized 
it  as  carcinoma  and  strongly  urged  immediate  removal,  as  the 
only  hope. 

She  was  extremely  constipated,  the  mouth  dry  and  the  saliva 
acid.  Being  placed  on  the  usual  dietary  and  medical  treatment 
it  was  recorded  in  2  weeks  that  she  felt  better  than  for  a  year. 
The  lump  was  materially  smaller,  though  the  edges  were  sharp 
and  nodular.  There  was  no  pain,  except  on  extreme  exertion 
in  doing  her  own  housework  and  caring  for  two  small  children. 
She  was  very  faithful  to  treatment,  generally  coming  every  week, 
and  6  months  later  it  was  recorded  that  the  mass  had  mark- 
edly diminished,  being  about  an  inch  in  diameter,  very  shallow, 
and  with  absolutely  no  pain.  Six  months  still  later  practically 
nothing  could  be  felt,  no  adenopathy.  A  little  over  a  year  after 
the  first  visit,  a  physician  visiting  the  clinic  was  told  that  she 
had  cancer,  and  was  asked  to  tell  which  breast  had  been  affected. 
After  careful  examination  he  decided  that  it  must  have  been  the 
left  breast,  instead  of  the  right,  as  there  was  a  slight  chronic 
mastitis  there.  At  intervals  later,  four  other  physicians  and 
surgeons  made  the  same  mistake.     Within  the  first  year  she  had 


CLINICAL  CONSIDERATIONS  AND  RESULTS  353 

been  pregnant,  the  child  dying  soon  after  birth.  She  was 
recently  at  the  clinic,  nearly  4  years  after  her  first  visit,  and 
there  was  still  nothing  in  the  right  breast  and  no  adenopathy; 
she  had  given  birth  to  still  another  living  child  not  long  before. 
One  of  my  assistants  reported  to  me  a  similar  case,  where  the 
cancerous  mass  had  disappeared  under  the  same  treatment,  and 
after  a  year  a  doctor  made  the  same  mistake  after  examining 
both  breasts. 

Case  XIX. — Primary  cancer  of  the  breast.  Mrs.  C.  M.  S. 
aged  35,  a  private  case,  seen  first  Jan.  15,  1917.  Six  months 
before  she  had  had  a  severe  blow  on  the  right  breast,  which  soon 
enlarged  and  was  painful,  it  had  been  poulticed  and  iodex 
applied.  When  first  seen  there  was  a  lump  the  size  of  an 
English  walnut,  quite  well  defined,  with  darting  pain;  no  axillary 
glands  were  felt,  though  small  enlargements  developed  2  weeks 
subsequently,  when  she  had  neglected  treatment.  Two  months 
later  the  right  breast  felt  almost  the  same  as  the  left,  though 
there  was  still  a  sharp  margin  in  one  place.  When  last  seen, 
about  18  months  after  the  first,  the  right  breast  was  normal,  but 
there  was  a  little  caking  in  the  left  breast,  and  some  little  feeling 
in  both  breasts  during  menstruation.  This  was  a  difficult  case 
to  handle,  as  she  had  much  care,  work,  and  worry,  keeping  a 
boarding  house,  with  her  mother  sick  at  times.  She  had  gastric 
disturbance,  and  was  much  constipated  before  treatment. 

Case  XX. — Primary  cancer  of  the  breast.  Miss  G.  D.  aged 
45,  was  under  treatment  for  eczema,  which  had  about  disap- 
peared, when  on  Jan.  22,  1917,  she  called  my  attention  to  a  large 
lump  in  the  left  breast,  which  had  existed  for  6  months  or  more. 
It  was  just  above  the  nipple,  the  size  of  an  egg,  with  sharp 
edges,  some  adherence  to  the  skin,  some  glandular  enlargement, 
and  sharp  pains  occasionally.  She  has  been  a  faithful  patient, 
under  frequent  observation,  and  after  about  a  year  it  was  re- 
corded that  the  lump  was  not  one-half  the  size,  was  softer  and 
without  any  sharp  edges,  and  that  the  glands  could  hardly  be 
felt;  there  was  scarcely  any  pain  expect  on  great  exertion.  She 
kept  her  weight  and  color  well  and  was  very  active. 

23 


354  CANCER 

Unfortunately  she  has  not  done  so  well  of  late,  now  nearly  4 
years  after  the  first;  for,  in  spite  of  faithful  treatment,  including 
x-rays  and  also  a  period  of  the  Williams'  proteal  treatment,1 
the  mass  has  remained  and  rather  increased,  and  also  the  axil- 
lary adenopathy.  We  can  find  no  reason  for  the  rebelliousness, 
but  it  is  the  rare  exception,  and  only  shows  that  we  have  not 
yet  reached  the  desired  goal. 

Case  XXI. — Primary  cancer  of  the  breast.  Mrs.  G.  K.  L. 
aged  59,  wife  of  a  physician,  was  first  seen  Aug.  30,  1918.  Four 
years  previously  a  lump  was  noticed  in  the  inner,  upper  quad- 
rant of  the  left  breast,  after  a  slight  blow  some  time  before. 
Since  then  the  breast  has  felt  heavy,  and  gradually  the  mass 
increased  in  size,  until  it  was  about  3^  inches  in  diameter, 
hard  and  characteristic,  with  some  enlarged  glands  in  the  axilla. 
Under  very  strict  diet  with  medication,  in  3  months  the  tumor 
had  diminished  one-half  the  size  and  was  much  softer;  she  had 
gained  4  pounds  was  of  a  good  color,  and  felt  better  than  for 
a  long  time.  Seen  rather  recently  the  breast  was  entirely 
normal  and  the  adenopathy  gone,  3  years  after  the  first  visit. 

Case  XXII. — Primary  cancer  of  the  breast.  Miss  L.  M.  aged 
55,  had  noticed  a  small  lump  in  the  left  breast  14  months  before 
the  first  visit,  Nov.  4,  1918,  which  had  been  kept  secret  until  a 
week  previously.  It  was  painful  from  the  first,  the  pain  increas- 
ing as  the  mass  grew,  until  of  late  it  had  caused  sleepless  nights. 
When  first  seen  there  was  a  large  mass,  2  or  3  inches  in  diameter, 
in  the  upper,  inner  segment,  near  the  nipple,  with  a  purplish- 
red,  protruding  area  an  inch  in  diameter.  The  whole  breast  was 
tense  and  the  axillary  glands  enlarged  and  painful  on  handling; 
there  was  no  supra-clavicular  adenopathy.  The  almost  imme- 
diate relief  to  many  symptoms  from  a  rigid  diet  and  appropriate 
medical  treatment  was  surprising.  In  a  week  the  tenseness  of 
the  breast  had  materially  lessened,  as  also  the  pain.  Two  weeks 
later  the  purplish  color  had  almost  gone  and  the  axillary  glands 
had  diminished  one-third  or  more,  all  verified  by  a  physician  who 
watched  the  case  with  me.     She  was  then  lost  sight  of,  for 

1  Williams,  "The  Proteomorphic  Theory,  Etc.  "     New  York,  1918. 


CLINICAL  CONSIDERATIONS  AND  RESULTS  355 

pecuniary  reasons,  after  being  charged  not  to  discontinue  any 
of  the  treatment. 

Case  XXIII. — Lale,  inoperable  cancer  of  the  breast.  Mrs. 
L.  H.  aged  36,  seen  first  Sept.  20,  1918,  had  a  lump  in  the 
left  breast  for  14  months,  which  had  gradually  increased  in  size, 
with  darting  pain,  disturbing  sleep  for  the  past  6  weeks,  it 
beginning  2  weeks  after  a  severe  blow  on  the  breast.  She  had 
seen  three  surgeons  of  prominence,  who  decided  that  it  was  too 
late  to  operate.  When  seen  there  was  a  large  hard  mass  in  the 
upper,  outer  segment  of  the  left  breast,  2  or  3  inches  in  diameter, 
adherent  to  the  skin  for  an  inch  or  so,  with  axillary  adenopathy, 
and  subsequently  some  supra-clavicular  adenopathy.  The 
saliva  was  acid  and  the  urine  secretion  insufficient  in  its  solid 
ingredients. 

For  a  month  or  two  she  did  well  under  active  dietetic  and 
medical  treatment,  gained  a  little  in  flesh,  and  slept  well  with- 
out pain,  but  had  some  darting  pains  in  the  daytime.  As  she 
and  her  husband  were  restless  under  the  treatment  given,  and 
insisted  on  an  operation,  I  consented  to  have  the  breast  and 
glands  removed  by  "chemical  extirpation,"  as  I  have  had  some 
of  my  cases  so  treated  at  the  New  York  Skin  and  Cancer  Hos- 
pital by  Dr.  Strobel,  with  good  results,  as  described  later,  in 
another  place.  This  was  done  on  October  31,  but  the  skin- 
grafting  was  delayed  until  November  26,  owing  to  the  difficulty 
of  reaching  the  axillary  glands.  The  graft  took  perfectly  over 
the  breast  area,  giving  a  smooth,  healthy  surface,  leaving  some 
raw  space  in  the  axilla,  to  be  treated  later.  The  slough  there 
separated  on  December  8,  and  skin-grafting  was  done  December 
13,  and  took  well.    Later  records  state  that  the  axilla  also  healed. 

After  this  she  did  well,  walking  out,  and  in  March  went  West 
for  several  weeks.  But  some  metastases  appeared  in  the  skin 
and  glands,  for  which  she  had  strong  radium  treatment  by  Dr. 
Janeway,  with  little  effect,  and  she  gradually  failed  in  strength, 
undoubtedly  from  internal  metastases,  and  died  on  July  12. 
The  saliva  continued  acid,  and  the  urinary  function  was  poor 
to  the  last,  in  spite  of  careful  treatment.     The  disease  had 


356  CANCER 

evidently  become  very  wide  spread,  before  coming  under  treat- 
ment, showing,  as  quoted  elsewhere  from  Dr.  Levin,  that  the 
bones  and  other  blood-making  organs  were  very  early  involved. 

Some  cases  were  also  reported  to  illustrate  what  can  be  done 
for  patients  where  the  disease  has  recurred  after  one  or  more 
surgical  removals. 

Case  XXIV. — Post-operative  cancer  of  the  breast.  Miss 
H.  K.  aged  45,  first  seen  Dec.  17,  191 7,  had  noticed  a  lump  in 
the  right  breast  in  April,  191 5,  which  was  removed  surgically 
within  3  months,  with  a  good  axillary  operation.  About  the 
middle  of  June,  19 17,  she  noticed  a  lump  in  the  left  breast,  in 
the  outer,  lower  segment.  When  seen  there  was  a  mass  the 
size  of  an  egg,  hard  and  with  some  irregular  nodosities,  the 
glands  along  the  pectoral  muscles  were  enlarged,  with  some 
doubtful  axillary  adenopathy.  She  was  always  constipated, 
and  the  saliva  was  acid,  the  menopause  had  not  yet  occurred. 
Placed  on  strict  diet  and  proper  medication,  she  was  very  faith- 
ful, though  living  in  a  distant  city,  coming  many  times  to  New 
York  for  treatment.  Within  a  few  months  the  tumor  became 
materially  smaller  and  soft,  and  no  adenopathy  could  be  de- 
tected. Like  so  many  of  these  cases,  she  was  lost  sight  of, 
but  there  is  reason  to  believe  that  all  treatment  was  continued 
and  that  the  disease  passed  away,  for  the  last  record  was  that 
she  "feels  very  well  indeed." 

Case  XXV. — Post-operative  cancer  of  the  breast. — Mrs.  B.  E. 
aged  49,  had  the  right  breast  removed,  by  a  very  complete 
axillary  operation  for  adeno-carcinoma,  by  one  of  the  leading 
surgeons  of  New  York,  on  Sept.  27,  1916.  She  had  never 
thought  of  the  breast  until  5  or  6  weeks  before  the  operation, 
the  lump  beginning  the  size  of  a  walnut  and  growing  rapidly 
in  extent,  with  glandular  enlargement. 

Four  months  after  the  operation  the  surgeon  sent  her  to  me, 
on  Jan.  30,  191 7,  with  recurrence  in  the  axilla  and  a  swollen 
arm,  with  pain  and  aching.  She  had  born  three  children  21, 
20,  and  13  years  of  age;  the  menses  had  ceased  5  years.  She 
had  long  had  persistent  constipation,  depending  on  cathartics 


CLINICAL  CONSIDERATIONS  AND  RESULTS  357 

all  the  time;  she  had  also  persistent  insomnia  for  the  last  year 
or  two,  lying  awake  until  2  or  3  a.m. 

She  was  a  very  faithful  patient,  coming  weekly  from  a  neigh- 
boring town,  and  for  a  while  seemed  to  do  well,  under  varied 
treatment  to  meet  existent  conditions,  but  taking  most  of  the 
time  the  mixture  of  acetate  of  potassa,  nux,  cascara,  and  rumex, 
often  referred  to.  But  in  spite  of  faithful  treatment  cutaneous 
nodules  kept  appearing,  though  very  slowly,  and  some  adeno- 
pathy, which  painting  with  ichthyol,  as  mentioned,  and  x-ray, 
seemed  to  control.  On  October  25  it  was  recorded  that  she  felt 
very  well,  had  a  great  appetite  (for  the  "green  card  diet") 
and  "sleeps  wonderfully,  with  no  nocturnal  urination,"  with 
which  she  had  formerly  been  troubled;  she  never  took  morphine 
or  any  opiate.  On  November  28  there  was  "very  great  im- 
provement," the  cutaneous  nodules  had  gone,  also  certain 
areas  of  diffuse  redness  which  had  appeared;  and  the  enlarged 
gland  which  had  formed  in  the  axilla  was  less. 

But  6  or  8  months  later  the  disease  seemed  to  increase,  in 
spite  of  her  diligent  attention  to  every  detail  of  treatment,  and 
slowly  signs  of  internal  metastasis  occurred,  as  well  as  supra- 
clavicular adenopathy  and  sternal  nodes,  for  which  radium 
emanation  tubes  were  inserted  by  Dr.  H.  H.  Janeway,  without 
appreciable  benefit.  Slowly  evidence  of  pulmonary  involve- 
ment came  on,  with  a  cough  and  distress,  and  the  chest  was 
tapped  several  times  and  large  amounts  of  fluid,  up  to  72  oz., 
removed.  She  finally  passed  away  Jan.  19,  1919,  2  years 
after  her  first  visit,  and  2  years  and  4  months  after  the  operation. 

While  the  ultimate  result  was  not  such  as  was  hoped  for,  or 
even  expected  by  the  surgeon  who  performed  the  relatively 
early  operation,  the  case  illustrates  what  was  referred  to  in 
Case  XXIII,  that  probably  there  was  at  the  time  of  operation 
already  a  far  more  extensive  spread  of  the  disease  in  the  blood- 
making  organs  than  was  suspected.  The  question  also  arises 
as  to  the  effect  of  traumatism  during  operation,  in  spreading 
the  disease  through  cut  lymph-  and  blood-vessels,  and  whether 
thorough   dietary   and   medicinal  measures   would   not   have 


358  CANCER 

checked  the  whole  process  at  the  first,  as  has  occurred  in  so 
many  cases,  of  which  a  few  illustrations  have  been  given.  It 
was  however,  a  comfort  to  have  her  husband,  an  unusually 
intelligent  gentleman,  write  to  me  when  announcing  her  death, 
"I  am  fully  convinced  that  you  have  added  considerable  to 
her  life,  in  comfort  and  length  of  days." 

Case  XXVI. — Inoperable  cancer  of  the  uterus.  Mrs.  N.  R.  M. 
aged  55,  first  seen  Dec.  27,  191 7,  had  been  examined  by  a 
number  of  gynaecologists,  who  reported  inoperable  cancer  of 
the  uterus,  with  not  over  6  months  to  live.  There  was  "a  great 
ragged  crater,  extending  back  to  the  rectum,  almost  into  the 
bladder  and  laterally  to  the  pelvic  wall."  All  this  was  con- 
firmed by  able  New  York  surgeons,  who  gave  her  but  a  few 
months  to  live.  For  9  months  she  had  had  a  profuse,  watery 
vaginal  discharge  and  occasional  bleedings,  with  pain  over  the 
pubis,  and  on  entering  the  hospital  the  discharge  was  bloody 
and  offensive.  She  had  always  been  habitually  constipated, 
and  the  saliva  was  found  to  be  very  acid. 

She  was  treated  as  other  uterine  cases  already  reported, 
dietetically  and  medicinally,  and  with  a  vaginal  douche  of 
very  hot  water,  one  pint,  with  half  a  teaspoonful  of  carbolic 
acid  and  two  of  borax,  thrown  in  deeply  and  strongly  with  a 
Davidson  bulb  syringe,  night  and  morning  and  later  at  noon. 
Within  about  a  month  there  was  a  marked  improvement  in  her 
looks  and  feelings.  The  douche,  which  was  frequently  ex- 
amined, came  away  clear,  with  no  blood  and  only  with  a  few 
shreds,  and  with  no  odor.  The  urine,  which  had  been  scanty, 
increased  to  quite  the  normal  amount  and  character,  and  the 
saliva  became  neutral.  She  slept  well  most  of  the  time,  with- 
out much  pain  in  the  pubic  region,  and  with  no  opiate,  and  it 
almost  seemed  as  if  she  would  pull  through. 

But  the  dullness  above  the  pubis  slowly  increased,  with 
bowel  obstruction  and  tympanites,  the  urine  became  scanty 
and  albuminous,  with  swollen  legs  and  feet,  and  other  signs  of 
kidney  involvement.  The  blood,  which  had  been  in  fairly 
good  condition,  showed  great  degeneration,  with  only  50  per 


CLINICAL  CONSIDERATIONS  AND  RESULTS  359 

cent  hemoglobin,  1,350,000  erythrocytes,  13,000  leucocytes, 
of  these,  70  per  cent  polynuclears,  4  transitional,  1  eosinophile. 
She  passed  away  very  peacefully  on  August  16,  without  requir- 
ing or  having  taken  a  particle  of  morphine  or  other  hypnotic, 
except  occasionally  a  small  dose  of  chloral  and  bromide,  at 
night,  when  sleepless. 

When  we  consider  the  original  condition,  and  the  course  of 
the  disease  in  this  patient,  with  her  constant  hopefulness 
and  comfort  during  these  8  months,  instead  of  six  months  or 
less,  as  prophesied,  as  compared  with  the  agony  often  suffered, 
and  the  morphine  commonly  required  or  taken,  the  benefit  of 
careful  medical  treatment  is  clearly  seen.  With  the  enormous 
infiltration  of  the  abdominal  viscera,  and  the  great  ulceration, 
the  case  was,  of  course,  hopeless  from  the  beginning. 

Case  XXVII. — Inoperable  cancer  of  the  uterus.  Mrs.  T.  F.  V. 
aged  64,  who  came  first  to  my  office  Nov.  23,  191 7,  was  a  very 
similar  case,  fatal  but  with  like  satisfactory  results.  She 
had  had  backache  and  vaginal  hemorrhage  for  3  months  before 
coming  under  treatment,  and  had  not  felt  well  since  June, 
losing  20  pounds  and  then  weighing  107.  Examined  by  a  sur- 
geon in  Maine,  and  a  gynaecologist  here,  she  was  found  to  have 
extensive  cauliflower  ulceration  of  the  cervix,  quite  inoperable. 
She  was  always  constipated,  the  urine  always  scanty,  and  the 
saliva  was  very  acid. 

Under  careful  dietetic  and  medical  treatment,  with  the  same 
vaginal  douche,  as  in  the  other  cases,  she  improved  greatly, 
gained  2  pounds,  and  "felt  like  a  different  person"  within  a  week, 
coming  frequently  to  the  office.  She  had  relatively  little  pain, 
never  required  an  opiate,  and  2  months  from  the  first  she  said 
that  she  "felt  more  free  from  pain  during  the  previous  week 
than  for  weeks  or  months."  The  douche  came  clear,  without 
blood.  Two  weeks  later  she  had  a  strange  attack,  with  suppres- 
sion of  the  urine,  and  became  irrational,  and  was  moved  to  the 
Hospital.  Two  weeks  later  she  was  perfectly  rational,  said  she 
had  no  pain,  but  wanted  to  go  home  to  Maine.  She  reached 
home  in  comfort' and  died  peacefully  25  hours  after  reach- 


360  CANCER 

ing  there,  Mar.  21,  1918.  Thus  she  lived  4  months  in  comfort, 
not  taking  a  particle  of  morphine  or  other  hypnotic,  and  died 
without  pain  in  peaceful  sleep,  as  reported  by  letter.  The 
case  of  course  was  hopeless  from  the  beginning. 

Case  XXVIIL— Cancer  of  the  stomach.  Mr.  B.  W.  aged  56, 
had  been  sickly  and  not  working  for  a  year  before  his  first  visit, 
Aug.  30,  1916.  He  had  seen  many  physicians  and  surgeons,  all 
diagnosing  cancer  of  the  stomach.  He  had  long  had  pain  in 
the  epigastrium,  with  swelling  and  hardness. 

On  examination  there  was  dullness  on  percussion  near  the 
pyloric  region,  and  a  mass  could  be  felt.  He  had  chronic 
constipation,  with  coated  tongue,  and  was  very  weak,  having 
lost  many  pounds.  Placed  on  a  rigid  diet  and  strict  regulations 
and  instructions  as  to  mastication  and  living,  with  medication, 
he  improved  greatly,  looking  and  feeling  much  better  at  the 
end  of  the  few  visits  he  made  from  another  city.  Seven  months 
later  I  learned  from  his  brother-in-law,  who  had  first  brought 
him  to  my  office,  that  the  patient  was  very  well  and  was  working 
again.  He  may  not  have  had  real  cancer  of  the  stomach, 
though  so  diagnosed  by  many  physicians  and  surgeons,  but  the 
history,  and  his  whole  appearance  and  the  objective  and 
clinical  symptoms,  with  his  cancerous  cachexia  and  loss  of 
weight,  etc.,  indicated  the  probable  correctness  of  the  diagnosis, 
and  the  result  certainly  was  most  satisfactory. 

Case  XXIX. — Cancer  of  the  rectum.  Mr.  J.  R.  aged  42,  first 
seen  June  13,  191 7.  Two  years  and  a  half  previously  he  had 
had  an  operation  for  ulcer  of  the  stomach,  and  had  had  no 
trouble  until  November  16,  when  he  was  given  Russian  oil  for 
obstinate  constipation.  About  a  month  before  his  visit  he 
was  seen  by  a  surgeon  of  prominence,  who  diagnosed  cancer  of 
the  rectum,  verified  by  microscopic  findings,  and  advised  an 
operation,  which  he  refused. 

When  seen  he  was  rather  thin  and  haggard,  having  lost  a 
good  many  pounds,  pulse  92  and  poor,  tongue  badly  coated. 
His  sleep  was  disturbed  by  having  to  get  up  three  or  four  times 
at  night  for  small,  thready  movements,  of  which  he  had  from 


CLINICAL  CONSIDERATIONS  AND  RESULTS  361 

12  to  15  in  24  hours.  On  examination  there  were  no  external 
signs  of  disease  and  digital  examination  revealed  little,  the 
disease  being  higher  up.  Under  dietetic  and  other  treatment 
the  stools  were  soon  reduced  to  4  in  the  24  hr.,  one  of  them  at 
night,  but  still  watery  and  generally  with  some  blood,  but  no 
pain.  Six  months  later  he  was  often  having  formed  movements 
of  good  size,  and  had  been  better  every  way  during  the  preced- 
ing month  than  for  a  year,  with  only  slight  pain  in  the  rectum 
occasionally.  There  was  still  a  little  blood  passed,  but  on 
April  12,  after  not  having  called  for  a  month,  it  was  recorded 
that  there  was  no  blood  in  the  passage. 

When  last  seen,  nearly  a  year  from  the  first,  he  was  in  about 
the  same  condition,  feeling  well,  and  had  been  steadily  at  work 
in  a  dry-goods  house,  all  the  time  while  under  treatment.  In 
view  of  the  unsatisfactory  results  commonly  attained  by 
operation,  and  the  distressing  condition  of  a  patient  when 
colostomy  is  performed,  the  results  in  this  case  may  be 
considered  satisfactory. 

Case  XXX. — Cancer  of  the  prostate.  B.  S.  aged  54,  had  long 
had  an  enlarged  prostate,  with  frequent  urination  day  and 
night.  He  had  lost  flesh,  especially  during  the  6  months 
preceding  his  first  visit,  Oct.  25,  191 7.  He  had  an  earthy 
cachectic  look,  was  thin  and  depressed.  On  examination  by  a 
surgeon  the  prostate  was  found  enlarged,  and  the  inguinal 
glands  on  both  sides  were  much  affected,  forming  great  masses, 
visible  to  the  eye,  there  being  no  lesions  on  the  penis.  Under 
the  green  card  diet  and  internal  medication  there  was  a  great 
change  in  a  few  weeks.  The  patient  felt  and  looked  much 
better.  The  glands  in  the  groin  had  subsided  greatly,  and 
shortly  thereafter  they  had  quite  disappeared,  the  cachexia 
was  gone,  and  he  had  not  an  ache  or  a  pain.  He  was  lost  sight 
of,  and  although  written  to  he  did  not  respond,  but  I  learned 
by  the  daily  paper  that  he  died  suddenly,  certainly  not  from 
his  cancer,  many  months  after  he  was  first  seen.  As  in  cancer 
of  the  stomach,  a  clinical  diagnosis  of  carcinoma  of  the  prostate 
is  often  difficult,  but  such  a  result  of  treatment  was  certainly 


362  CANCER 

satisfactory,  and  preferable  to  surgical  interference,  with  all  its 
uncertainties. 

Case  XXXI. — Cancer  of  the  kidney. — Mr.  H.  H.  B.,  aged  55, 
had  been  indisposed  for  a  year,  his  color  was  bad,  and  work  was 
difficult  to  accomplish,  he  being  a  clergyman  in  a  far  distant 
town.  On  Aug.  29,  1916  he  passed  blood  in  the  urine,  which 
continued,  often  coagulated,  with  much  pain  in  the  back. 
The  x-ray  showed  nothing,  nor  cystoscopy,  except  blood  coming 
from  the  right  ureter.  The  right  kidney  was  removed  on 
September  1,  in  another  city,  and  found  to  be  enlarged  many 
times,  weighing  over  2  pounds,  and  shown  to  be  cancerous  micro- 
scopically. He  made  a  good  recovery,  and  had  no  pain  while  in 
bed,  3  weeks,  but  on  walking  had  pain  in  the  left  side,  increasing 
toward  afternoon,  and  making  life  miserable  up  to  his  coming 
under  treatment,  Jan.  20,  191 7.  He  then  weighed  174^ 
pounds,  and  was  a  large  meat  eater  and  very  fond  of  milk  and 
eggs.  He  had  never  had  any  restriction  in  diet,  nor  directions 
as  to  eating,  nor  other  treatment  of  any  kind. 

Under  strict  "green  card"  diet  and  varied  medication  at 
frequent  office  consultations,  with  voluminous  notes,  and  lat- 
terly by  correspondence,  he  has  now  been  under  my  care  for  over 
4  years.  He  has  been  able  to  do  his  work  all  the  time,  has 
gained  14^  pounds  in  weight,  and  for  long  periods  has  been 
free  from  pain,  although  at  times  when  overworked  or  strained 
he  has  pain  over  the  remaining  kidney.  Notes  from  time  to 
time  record  that  he  was  "doing  normal  work,"  "stands  well  the 
hardest  strains,"  "felt  better  than  for  years,"  "never  had  so 
good  a  color  or  circulation,"  etc. 

The  urine  has  been  watched  and  actually  measured  and 
recorded  daily  during  all  this  time,  and  frequently  analyzed 
volume trically.  It  has  commonly  averaged  over  50  oz.  daily, 
the  various  ingredients  are  generally  about  normal,  except  that 
the  urea  is  apt  to  be  low,  owing  to  his  vegetarian  diet.  He  has 
been,  and  I  believe  will  be  very  faithful  to  treatment,  which  has 
certainly  prolonged  his  life  and  usefulness,  and  given  great 
comfort  and  ease.     How  long  it  will  be  necessary  to  continue 


CLINICAL  CONSIDERATIONS  AND  RESULTS  363 

active  treatment  it  is  difficult  to  say.  A  relapse  to  his  former 
method  of  living,  and  entire  neglect  of  protective  treatment, 
might  naturally  be  expected  to  again  induce  again  a  serious 
involvement  of  the  remaining  kidney.  He  has,  of  course,  never 
taken  a  particle  of  morphine  or  other  hypnotic,  the  pains  occur- 
ring at  times  being  largely  relieved  by  the  frequent  use  of  aspirin. 
A  very  recent  medical  letter,  4  years  after  first  visit,  reports  a 
continued  well  being,  but  full  treatment  is  still  continued,  as  he 
has  repeatedly  had  threatenings  of  trouble  when  careless. 

Case  XXXII.— Cancer  of  the  bladder.  Mr.  G.  W.  H.  aged 
68,  had  been  under  my  care  for  a  number  of  years,  for  various 
difficulties,  when  on  Mar.  14,  1914,  he  brought  two  specimens  of 
urine  with  clots  of  blood  and  a  considerable  amount  of  albumen 
in  the  evening  sample.  There  had  been  no  special  pain  in  the 
back,  nor  on  passing  urine.  The  urine  cleared,  but  3  days  later 
he  was  again  passing  blood  and  was  feeling  weak,  and  thought 
he  had  lost  2  pounds  in  weight.  He  had  to  urinate  every 
2  hours,  twice  at  night;  the  blood  appeared  at  the  end  of 
urination.     Blood  pressure  160  systolic. 

On  April  2,  he  was  cystoscoped  by  Dr.  A.  R.  Stevens,  who 
found  the  bladder  mucosa  normal,  except  near  the  left  ureteric 
orifice.  Just  above  this  there  was  a  small,  defined,  sessile 
mass,  with  small  blood  vessels  over  its  surface,  pretty  typical 
of  early  carcinoma  of  the  bladder  wall.  Radical  excision  was 
advised,  or  else  fulguration.  Declining  these  very  positively 
he  was  treated  medically  for  a  month,  when  he  yielded  to  my 
persuasion  and  on  May  7,  Dr.  Stevens  treated  the  lesion  by 
fulguration,  which  was  repeated  several  times.  On  October 
22,  he  was  cystoscoped  and  no  sign  of  recurrence  was  seen,  only 
a  scar.  Later  there  appeared  to  be  some  recurrence  which  was 
treated,  and  repeated  cystoscopy  by  three  urologists,  showed 
no  signs  of  recurrence  up  to  the  time  when  his  case  was  reported, 
nearly  5  years  after  the  first  symptoms  were  observed. 

But  some  time  later  blood  again  appeared  in  the  urine  and 
he  was  found  to  have  a  large,  elastic  prostate  ("not  carcinoma") 
and  prostatectomy  was  performed.     Being  still  under  constant 


364  CANCER 

observation  and  medical  treatment,  he  has,  however,  some 
trouble  with  urination,  sometimes  with  a  little  blood,  said  to 
come  from  the  deep  urethra,  but  as  far  as  can  be  learned,  with 
no  recurrence  of  the  bladder  trouble,  now  nearly  7  years  since 
its  first  appearance.  During  all  this  time,  under  strict  regimen 
and  varied  medication,  he  has  maintained  his  general  health, 
color,  and  weight  and  has  pursued  his  usual  business. 

Case  XXXIII. — Cancer  of  the  tongue.  Mr.  K.  M.  A.  aged 
59,  first  seen  Sept.  n,  1918,  first  noticed  an  irritation  of  the 
right  side  of  the  tongue,  from  a  broken  tooth,  in  May,  and  on 
May  n  it  was  "operated  on  with  a  knife,"  and  healed,  so  that 
he  went  to  work  on  May  20,  with  no  pain  for  3  weeks.  It 
then  began  to  ulcerate  and  '  'a  knife  was  again  used  and  it  was 
cauterized"  on  August  5,  and  he  left  the  hospital  on  August 
11,  5  weeks  before  his  visit  to  my  office.  Since  that  time  the 
trouble  had  been  increasing  rapidly,  until  when  first  seen  the 
tongue  was  enormous,  filling  the  buccal  cavity,  with  a  large, 
ulcerative  patch,  an  inch  and  more  wide  with  sharp,  hard  edges. 
The  sub-maxillary  glands  were  large,  hard,  and  matted  together, 
and  the  case  was  considered  inoperable  by  the  surgeons  whom 
he  had  seen.  The  saliva  was  very  acid,  and  the  urine  contained 
much  indican,  also  oxalates  and  phosphates. 

Being  placed  on  a  rigid  diet,  with  absolutely  no  smoking, 
alcohol,  coffee,  or  tea,  and  with  a  mixture  of  acetate  of  potassa, 
nux  vomica,  cascara,  and  rumex,  the  improvement  began  almost 
at  once.  He  also  used  as  a  mouth  wash  a  saturated  solution 
of  bi-carbonate  of  soda,  diluted  more  or  less  if  necessary,  held 
in  the  mouth  for  some  minutes,  quarter  of  an  hour  before  and 
after  taking  food.  He  could  take  only  liquid  food,  having 
great  difficulty  in  swallowing.  By  the  end  of  3  months  the 
change  was  most  remarkable.  The  tongue  had  greatly  dimin- 
ished in  size  and  the  ulceration  had  actually  ceased,  though 
there  was  still  hardness.  He  swallowed  much  better,  the  jaws, 
which  at  first  opened  only  a  little,  opened  much  wider,  he  could 
chew  some,  and  the  glands  beneath  the  jaw  were  much  smaller 
and  less  adherent,  and  quite  movable,  as  was  verified  by  two 


CLINICAL  CONSIDERATIONS  AND  RESULTS  365 

physicians.  He  remarked  the  "great  improvement  in  his  condi- 
tion "  and  his  wife  said  "the  change  from  the  first  is  marvellous." 
He  still  complained  of  some  pain  in  the  neck,  running  up  to 
the  head,  but  he  has  never  taken  any  morphine  or  any  anodyne. 
When  seen  later  the  improvement  was  still  more  marked. 

But,  alas,  the  knife  and  cauterization  had  already  done  their 
deadly  work,  and  deeper  glands  and  organs  became  involved, 
and  I  was  summoned  to  Brooklyn  a  month  or  two  later  to  find 
the  neck  enormously  swollen,  with  abscesses  forming,  though 
the  tongue  remained  relatively  well.  I  did  not  hear  from  him 
again  and  I  presume  that  he  succumbed  to  the  disease. 

In  this  instance  a  benign  lesion  on  the  tongue,  from  a  ragged 
tooth,  was  transformed  into  a  malignant  one  by  injudicious 
treatment,  and  is  in  striking  contrast  to  a  case  which  will  be 
reported  later. 

Case  XXXIV. — Cancer  of  the  tonsil.  Mr.  F.  F.  aged 
72,  came  under  observation  and  treatment  in  my  office  on  Oct. 
2,  1918.  For  3  months  he  had  felt  a  pressure  of  something 
wrong  in  the  right  side  of  the  throat,  and  on  September  3  had 
had  some  sort  of  an  operation  from  within,  the  nature  of  which 
could  not  be  determined.  He  had  seen  many  physicians  and 
surgeons  who  advised  a  complete  operation  from  the  outside,  that 
was  refused.     A  Wasserman  had  been  taken  and  found  negative. 

On  examination  the  right  tonsil  was  found  to  be  the  seat  of  an 
ulcerative  process,  nearly  an  inch  in  diameter,  very  hard  to  the 
touch,  and  sharply  defined,  with  hard  edges  and  considerable 
inflammatory  action  of  the  surrounding  parts,  reaching  almost 
over  to  the  left  tonsil.  The  glands  beneath  the  jaw  were  greatly 
enlarged,  the  size  of  a  large  walnut,  but  rather  movable.  The 
saliva  was  very  acid.  He  had  been  in  the  habit  of  taking  beer 
twice  daily,  and  smoking,  which,  of  course  were  stopped,  and 
he  was  placed  on  a  complete  dietetic  and  medical  treatment, 
with  the  soda  gargle,  held  a  good  while  in  the  throat,  quarter  of 
an  hour  before  and  after  each  meal. 

Under  these  measures  he  began  to  improve  from  the  first, 
and  within  two  months  the  ulceration  had  about  ceased,  and 


366  CANCER 

much  of  the  adjoining  inflammatory  action  subsided.  The 
hardness  had  largely  gone,  but  the  edges  were  still  sharp  and 
somewhat  hard.  The  gland  in  the  neck  had  diminished  to 
the  size  of  a  small  almond.  He  remarked  "I  feel  all  right  and 
have  nothing  to  complain  of."  A  little  later  it  was  recorded 
that  there  was  still  slight  marginal  hardness,  but  superficial, 
and  the  gland  was  smaller  and  freely  movable.  "I  feel  per- 
fectly well,"  "find  no  complaint  of  any  kind." 

This  patient  has  been  under  constant  observation  and  treat- 
ment for  2  years  more  since  then  reported,  working  at  his 
regular  employment,  and  has  repeatedly  used  much  the  same 
expressions,  quite  a  contrast  to  the  result  commonly  observed 
in  such  cases.  But  in  the  last  6  months  he  being  now  nearly 
75,  he  has  been  failing,  possibly  from  neglecting  some  item  of 
treatment,  for  he  can  call  from  another  city  but  seldom,  for 
financial  reasons,  and  the  disease  has  attacked  the  other  tonsil, 
with  much  glandular  swelling  on  the  left  side,  and  he  will  prob- 
ably succumb  to  the  disease  before  very  long.  Over  2  years  of 
comfortable  life,  however,  have  been  secured  in  spite  of  the 
injury  inflicted  by  "some  sort  of  an  operation  from  within" 
on  Sept.  3,  19 1 8,  for  if  left  alone,  with  the  progress  the  disease 
was  making,  he  would  probably  have  been  in  his  grave  long  ago. 

Case  XXXV.— Cancer  of  the  Up.  Mr.  W.  H.  N.  an  unusually 
intelligent  gentleman  aged  45,  from  Boston,  had  a  slowly 
growing  cancer  of  the  lower  lip  for  several  months,  for  which 
an  immediate  radical  operation  was  insisted  on  by  several 
prominent  surgeons  there,  and  by  his  friends. 

When  first  seen  Feb.  6,  191 7  there  was  an  oval,  epithelioma- 
tous  lesion,  just  to  the  left  of  the  medium  line,  about  a  half  an 
inch  in  diameter,  and  raised  a  line  or  so,  as  characteristic  as 
could  be,  with  possible  slight  adenopathy  below  the  chin.  He 
was  placed  on  the  rigid  diet  and  medication,  with  no  smoking, 
liquor  or  beer.  The  surface  was  kept  covered  night  and  day, 
even  at  meal  time,  with  an  ointment  (1$  Ichthyol  3ss  Zinci 
oleat.  3ss  Unguent,  aquae  rosae  gi).  This  was  spread,  with  a 
steel  spatula,  on  the  thinnest  possible  portion  of.  absorbent 


CLINICAL  CONSIDERATIONS  AND  RESULTS  367 

cotton,  large  enough  to  fully  cover  the  sore,  pressed  down,  so 
as  to  make  it  adhere  firmly,  and  was  replaced  twice  a  day  or 
oftener  if  desired,  and  the  new  plaster  was  to  be  spread  in 
advance  and  reapplied  instantly,  never  leaving  the  sore  exposed 
for  a  moment.  I  have  used  this  method  in  many  cases,  and 
it  is  surprising  how  deft  patients  become  in  keeping  on  the 
application,  even  during  meals  and  at  night. 

In  a  week  there  was  a  decided  change,  the  mass  being 
much  softer,  though,  of  course,  still  with  decided  induration. 
This  ointment  was  changed  somewhat  from  time  to  time,  with 
occasionally  1  per  cent  of  powdered  salicylic  or  pyrogallic 
acid  added,  reverting  at  times  to  the  first  ointment,  or  to  a 
calamine  and  zinc  ointment,  when  these  seemed  a  trifle  irritat- 
ing. Nine  months  later  he  kindly  presented  himself  at  my 
lecture  at  the  New  York  Skin  and  Cancer  Hospital  with  the 
disease  about  gone,  and  gave  the  physicians  a  remarkable  talk 
on  cancer  of  the  lip  and  its  treatment.  He  stated  that  he  was 
a  Harvard  graduate  and  had  studied  medicine  a  while,  and 
knew  what  he  was  talking  about,  from  wide  acquaintance  with 
physicians  and  surgeons,  and  urged  them  seriously  to  follow  up 
the  line  of  medical  treatment  of  cancer  if  I  were  called  away. 

He  became  deeply  interested  in  war  work,  traveling  over  the 
country  for  the  Government,  and  I  did  not  see  him,  but  a  year 
later  he  wrote  enthusiastically  about  his  case.  Very  recently, 
nearly  4  years  after  first  seeing  him,  he  hailed  me  in  the  street, 
and  we  spent  some  time  together;  the  lip  was  and  had  long 
been  perfectly  well. 

Case  XXXVI. — Cancer  of  the  lip.  An  interesting  case  was 
overlooked  in  my  previous  report,  of  a  Mr.  V.  F.  aged  40,  who 
came  to  me  Oct.  17,  19 15.  He  had  a  very  characteristic  cancer 
of  the  right  side  of  the  lower  lip,  firm  and  moderately  ulcerated. 
Under  diet  and  careful  medical  treatment,  internal  and  external 
it  steadily  improved,  until  on  April  10,  1916,  it  was  recorded 
that  it  was  well,  with  absolutely  no  hardness  left.  A  year 
later  another  patient  with  lip  cancer  looked  him  up,  and  the 
man  actually  could  not  remember  just  where  the  lesion  had  been, 


368  CANCER 

so  perfectly  well  was  he.  He  was  a  butcher,  who  had  been 
in  the  habit  of  consuming  much  meat,  which,  of  course,  was 
stopped  entirely,  and  replaced  by  an  absolutely  vegetarian  diet. 

We  have  now  reviewed  the  histories  of  36  cases  of  undoubted 
cancer,  some  shown  by  microscopic  examination  to  be  cari- 
mona,  and  all  of  them  diagnosed  as  such  by  at  least  one,  and 
often  by  many  other  physicians  and  surgeons,  while  the  cases 
recurrent  after  operation  are  unquestionable.  The  results  of 
medical  treatment  speak  for  themselves.  A  large  share  have 
clinically  recovered,  some  have  died,  especially  those  who  had 
had  from  one  to  four  surgical  operations.  Some  were  absolutely 
hopeless  when  first  seen,  but  even  in  the  worst  cases  there  has 
been  an  amelioration  of  distressing  symptoms  and  a  prolonga- 
tion of  life  which  have  been  indeed  gratifying.  When  all  this  is 
compared  with  the  ordinary  course  of  cancer  cases,  it  does  seem 
that  we  are  at  least  on  the  right  track  concerning  the  treatment 
of  this  dire  disease. 

In  the  second  volume  I  presented  a  table  of  the  cases  which 
had  been  observed  up  to  Jan.  1,  191 7,  to  this  I  will  now  add 
those  seen  in  private  practice  from  that  date  to  Jan.  1,  192 1, 
of  which  full  notes  are  before  me.  It  is  understood  of  course, 
that  not  all  of  them  have  been  under  complete  and  satisfactory 
dietetic  and  medical  treatment.  For  many  cases  were  seen 
but  a  single  time  in  consultation,  many  made  but  one  or  two 
visits,  and  evidently  were  not  satisfied  with  the  outlook; 
some  have  wearied  with  the  restraint  and  the  prospect  of 
prolonged  treatment,  and  undoubtedly  many  have  not  carried 
out  every  item  of  treatment  perfectly;  again,  some  have  thought 
that  there  was  not  rapid  enough  progress,  and  some  have  been 
drawn  away  by  the  lure  of  surgery,  hoping  that  in  their  case 
at  least  it  might  possibly  be  successful,  and  others  have  been 
led  to  try  #-ray  or  radium. 

But  a  very  considerable  proportion  of  the  patients  have  been 
faithful  to  the  end,  and  have  warmly  appreciated  the  results 
obtained.  I  may  truly  say  that  I  have  not  selected  my  cases, 
but  have  always  accepted  any  and  every  one,  however  hopeless 


CLINICAL  CONSIDERATIONS  AND  RESULTS 


369 


it  seemed,  because  from  experience  I  knew  that  some  measure 
of  benefit  would  be  obtained.  The  cases  which  have  been  and 
will  be  presented,  are  assuredly  selected  from  among  very 
many  others  more  or  less  similar,  to  illustrate  certain  features 
which  might  help  the  profession  in  mastering  the  disease.  In 
a  very  few  instances  indeed  have  I  yielded  to  the  importunity 
of  the  patient,  the  physician,  or  friends  and  have  acceded  to 
having  a  surgical  operation  performed,  and  I  do  not  by  any 
means  deny  that  this  may  possibly  be  advisable,  in  certain  rare 
cases.  But  it  is  in  the  early  cases,  which  medical  men  are  so  apt 
to  think  as  most  suitable  for  operations,  that  we  find  the  best, 
and  almost  invariably  successful,  results  from  medical  treatment. 
During  the  past  4  years,  from  Jan.  1,  1917,  to  Dec.  31,  1920, 
there  have  been  in  my  office  recorded  histories  of  cases  of  malig- 
nant disease,  as  follows:  Carcinoma  187,  Sarcoma  12,  Cutaneous 
epithelioma  30,  a  total  of  229  cases  of  neoplastic  disease.  The 
hospital  material  is  now  excluded,  as  judgment  is  better  made 
concerning  the  more  intelligent  class  of  patients  seen  in  private 
practice  than  in  those  met  within  the  Outpatient  Department 
or  in  Hospital  wards,  and  records  are  apt  to  be  more  accurate. 
Adding  these  figures  to  those  given  in  the  second  volume  on 
'  'Cancer,  Its  Cause  and  Treatment"  we  have  the  following  table: 


Cases  of  Neoplastic  Diseases 


Carcinoma 


Males      Females      Total 


Breast 

Uterus 

Lip 

Tongue  and  Mouth 

Head  and  Neck 

Oesophagus,  Stomach,  Liver,  and  Intestine 

Kidney,  Bladder,  and  Prostate 

Other  localities 

Epidermoid  carcinoma  (Epithelioma)  of  the  skin 
Sarcoma 

Totals 

24 


35 
4i 
4i 
34 
5 
18 

444 
25 


646 


235 

22 

3 

6 

14 

17 

2 

7 
261 

24 


59i 


238 

22 
38 
47 
55 
5i 
7 
25 
7°5 
49 


1237 


370  CANCER 

There  are  also  records  of  dozens  of  instances  in  practice  or 
consultation  where  carcinoma  or  sarcoma  was  suspected  or 
feared,  which  proved  to  be  simple,  innocent  affections;  such 
were  chronic  mastitis  or  cysts,  adenoma,  fibroma,  lipoma, 
enchondroma,  angioma,  etc.  benign  in  character,  as  also  gastric, 
intestinal,  renal,  or  other  disorders,  to  say  nothing  of  late 
syphilitic  and  tubercular  lesions,  thought  to  be  cancer,  and 
sometimes  treated  as  such;  all  of  these,  of  course,  are  excluded 
from  our  study,  as  were  also  some  case  papers  with  the  diagnosis 
"Cancerphobia."  This  latter  term,  however,  is  a  good  sugges- 
tion for  the  lay  mind,  harassed  by  the  fear  of  hereditary  trans- 
mission, or  alarmed  through  newspaper  or  other  articles,  or  by 
occurrences  to  friends,  if  considered  from  a  broad  medical 
aspect,  and  if  it  will  lead  to  the  very  early  recognition  of  the 
existence  of  the  true  disease,  and  its  proper  treatment. 

Epithelioma  of  the  skin,  although  included  with  cancer  in  the 
Mortality  Statistics  of  the  United  States,  and  often  elsewhere, 
is  excluded  from  our  present  study  of  carcinosis  as  a  disease,  for 
reasons  shortly  to  be  given,  and  will  be  only  briefly  mentioned, 
with  some  practical  suggestions  concerning  its  treatment. 

Carcinoma,  or  true  cancer,  has  been  and  will  be  considered  as 
it  affects  various  organs  and  localities,  together  with  its  different 
stages.  It  will  be  noticed  that  no  attempt  is  made  to  differ- 
entiate the  various  forms  of  deranged  cell  activity,  chemically  or 
microscopically,  as  discussed  by  Ewing  and  others,  for  in  the 
broadest  sense  all  carcinomata  are  practically  but  different 
manifestations  of  the  same  real  disease,  carcinosis,  wherever 
the  neoplasm  occurs,  just  as  are  the  various  manifestations  of 
gout,  tuberculosis,  syphilis,  etc.  True  cancer  is  simply  a  depar- 
ture of  normal  epithelial  cells,  mainly  of  the  glands  or  lining  mem- 
branes of  different  organs,  from  a  normal  state  of  life.  The 
forms  taken  by  the  neoplasm,  as  also  its  histological  features, 
will  naturally  vary  according  to  the  tissue  in  which  it  exists,  and 
for  other  reasons  as  yet  unknown;  this  is  especially  observed  in 
regard  to  sarcoma. 

For  many  years  I  have  observed  that  those  cases  of  any  form 


CLINICAL  CONSIDERATIONS  AND  RESULTS  37 1 

of  malignant  disease  have  always  done  worse  after  a  biopsy, 
curetting,  surgery  or  any  measure  breaking  the  surface  and 
facilitating  the  entrance  of  cancerous  elements  into  the  blood 
vessels  and  lymphatics.  While  I  am  glad  to  take  advantage  of 
microscopical  studies  already  made,  I  do  not  recall  an  instance 
for  many  years  where  I  have  sanctioned  a  biopsy,  as  it  always 
does  harm,  as  many  now  agree. 

We  have  already  seen  that  the  beginning  of  these  disturbances 
can  often,  but  not  always,  be  traced  to  some  local  irritation. 
This  disturbs  the  equilibrium  of  the  cell  nuclei,  by  which  means 
they  are  induced  to  change  their  form  and  that  of  the  cells,  more 
or  less,  and  to  enter  upon  their  erratic  and  destructive  course; 
this  occurs  and  is  continually  furthered  through  errors  of  meta- 
bolism, or  by  the  manner  in  which  they  receive  and  respond  to 
the  wrong  nutriment  offered  to  them.  This  latter  we  found  to 
be  partly  due  to  the  erroneous  pabulum  furnished  by  the  food 
and  drink  taken,  and  partly  due  to  the  faulty  action  of  the 
various  organs  of  the  body,  including  the  endocrinous  glands 
and  the  blood  making  and  destroying  agencies  of  the  body;  for 
all  of  these  are  concerned  in  producing  and  purifying  the  blood 
stream,  from  which  all  the  cells  of  the  body  secure  their  nutriment. 

Sarcoma  will  be  considered  separately,  as  microscopically 
it  is  a  different  affair,  namely  a  disease  of  the  connective  tissue, 
or  mesoblastic  elements.  But  practically  it  is  of  the  same 
nature  as  carcinoma,  being  also  due  to  faulty  nutrition  and 
metabolism,  and  yielding  to  practically  much  the  same  measures 
as  that  disease.  Benign  neoplastic  growths  and  adiposis  are 
undoubtedly  due  to  wrong  nutritive  action. 

CUTANEOUS  EPITHELIOMA 

It  is  not  worth  while  to  attempt  to  analyze  the  notes  of  the 
705  cases  of  ordinary  cutaneous  epithelioma,  many  of  which 
were  small  and  superficial,  and  easily  cured.  Females  formed 
37  per  cent  of  the  patients,  which  conforms  to  the  proportion 
of  deaths  attributed  to  it  in  the  United  States  Special  Mortality 
Report  on  cancer  for  1914. 


372  CANCER 

In  the  United  States  Mortality  Reports  for  1918,  the  deaths 
from  cancer  of  the  skin  were  put  down  at  3.4  per  cent  of  all  cases 
of  carcinoma,  of  all  kinds  in  any  locality.  This  seems  a  very 
large  proportion,  but  these  deaths  must  have  occurred  in  cases 
which  had  been  dreadfully  maltreated  in  their  earlier  stages; 
for  we  do  continually  see  certain  cases  which  have  been  almost 
maliciously  stimulated  or  goaded  on  to  severe,  malignant  action 
by  injudicious  therapeutic  measures.  About  the  worst  mal- 
practice is  the  almost  universal  employment  of  nitrate  of  silver, 
which  should  be  forbidden  by  law  in  these  cases.  For  I  can 
find  no  personal  record  of  any  case  which  had  been  properly 
treated  from  the  beginning  and  had  resulted  in  death,  although 
I  have  seen  a  number  of  patients  where  the  disease  had  so  far 
progressed  under  previous  management  that  they  probably 
ended  fatally,  in  other  hands.  Quite  possibly  cases  have  been 
reported  in  the  United  States  Statistics  as  epithelioma  of  the  lip, 
tongue,  buccal  cavity,  and  even  of  the  cervix  uteri,  which  should 
be  more  properly  classed  as  carcinoma  of  those  regions. 

Cutaneous  epithelioma,  especially  about  the  face  is  excluded 
from  our  study  of  real  cancer:  (1)  Because  its  cause  and 
treatment  are  almost  entirely  local,  and  so  the  disease  does  not 
greatly  concern  our  general  inquiry  as  to  the  internal  or  con- 
stitutional cause  and  treatment  of  real  carcinoma.  (2)  Because 
dietary  and  medicinal  measures  seem  to  have  relatively  little 
effect  on  cutaneous  epithelioma,  except  sometimes  in  the  later 
stages;  where  the  disease  has  caused  great  ravages,  showing 
that  a  cancerous  dyscrasia  has  existed,  and  (3)  Because,  if 
the  proper  treatment  of  cutaneous  epithelioma  is  begun  early 
and  carried  out  faithfully,  it  need  never,  or  exceedingly  seldom, 
acquire  such  a  severity  as  is  often  depicted  by  overzealous 
surgeons  who  advocate  only  the  knife.  It  is  not  denied,  of 
course,  that  complete  and  early  excision  may  cure  such  a  local 
disease,  in  many  instances,  but  it  is  wrong  to  infer  from  this 
that  true  carcinoma  can  be  successfully  treated  in  this  manner, 
(for  even  surgeons  now  agree  that  this  latter  is  impossible) 
moreover,  the  ultimate  results  of  the  excision  of  epithelioma  are 


CLINICAL  CONSIDERATIONS  AND  RESULTS  373 

often  very  deforming,  whereas  if  properly  treated,  early  lesions 
leave  practically  no  scar. 

Inasmuch  as  the  border  line  between  superficial  and  deep 
misbehaviour  of  epithelial  cells  is  frequently  so  indistinct,  it  is 
often  difficult  at  first  to  designate  as  carcinoma  all  cases  in 
certain  regions  that  might  possibly  belong  there.  On  looking 
over  the  case  papers  I  find  a  number  in  which  the  first  diagnosis 
was  entered  as  epithelioma,  but  where  the  disease  proved  so 
malignant  in  its  course  that  they  should  certainly  be  included  in 
the  carcinomatous  class;  these  included  also  cancer  of  the  lip 
and  buccal  cavity,  likewise  certain  ones  of  the  face  and  neck, 
which  from  their  metatastic  tendency,  belong  to  the  latter. 

In  regard  to  the  treatment  of  cutaneous  epithelioma,  this 
must  vary  greatly  according  to  the  stage  of  the  disease  and  its 
locality.  In  my  earlier  years  I  employed  frequently  the 
Marsden's  paste1,  consisting  of  equal  parts  of  arsenious  acid 
and  powdered  gum  acacia,  mixed  with  water  in  a  thick  paste  at 
the  time  of  using.  This  is  spread  on  surgeon's  lint,  cut  to  the 
size  of  the  lesion  and  held  in  place.  In  from  2  to  4  days  a 
distinct  line  of  demarcation  around  the  diseased  parts  is  seen, 
and  poultices  are  to  be  then  kept  applied,  changed  every  few 
hours,  until  the  resulting  slough  separates,  and  repeated, 
afterwards  until  good  cicatrization  results;  and  often  no  other 
dressing  is  used,  even  until  all  is  healed.  Marsden  advises 
the  application  of  the  arsenic  paste  to  be  not  over  1  square  inch 
at  a  time.  The  arsenic  seems  to  have  a  selective  action  for  the 
diseased  epithelial  tissue,  and  in  many  cases  I  had  perfect  and 
permanent  results,  with  trifling  disfigurement.  This  is  still  a 
useful  measure,  where  others  cannot  well  be  employed. 

Later  I  curetted  the  lesion  very  thoroughly,  and  when  the 
bleeding  was  staunched  by  pressure,  the  surface  was  covered 
with  powdered  pyrogallic  acid,  and  in  this  way  I  secured  some 
excellent  results  in  59  cases.2 

Marsden,  "A  New  and  Successful  Mode  of  Treating  Certain  Forms  of 
Cancer."    London,  1874,  p.  83. 

2Bulkley  and  Janeway,  "Study  of  400  Cases  of  Epithelioma  in  Private 
Practice."  Medical  Record,  Mar.  n,  1908. 


374  CANCER 

Early  after  the  introduction  of  the  #-ray,  in  1903,  the  disease 
was  almost  invariably  treated  by  this  means,  and  even  up  to 
the  present  time  I  find  it  the  best  treatment  in  certain  cases, 
and  in  scores  or  even  hundreds  of  instances  the  lesion  has  been 
seen  to  slowly  melt  away  and  a  perfect  result  to  follow,  with 
little  or  no  scar.  The  results  have  been  commonly  permanent, 
though  sometimes  slight  recurrences  have  happened,  which 
in  turn  yielded  quickly  to  the  #-ray.  Some  judgment  and 
experience,  of  course,  are  necessary,  as  harm  may  result  from 
the  injudicious  or  inexperienced  use  of  this  two-edged  weapon; 
there  should  never  be  a  burn.  I  have  thus  repeatedly  cured 
epithelioma  about  the  eye,  with  no  harm  to  the  organ.  I 
have  always  employed  the  original  gas  tube,  and  not  the 
Coolidge  tube,  as  I  believed  that  a  prolonged  application  of  the 
ray  is  more  penetrating  and  permanently  curative,  than  the 
short,  strong  exposure;  even  as  in  the  use  of  radium  and  thorium 
the  action  is  prolonged,  in  order  to  secure  benefical  affect. 

Radium  has  been  exploited  much  in  later  years,  but  I  have 
had  relatively  little  personal  experience  with  it,  though  I  used 
it  some  years  ago  in  the  Hospital,  with  a  measure  of  success. 
I  am  surprised,  in  looking  over  my  histories,  however,  to  see 
how  many  times  it  had  been  previously  employed  without  the 
expected  results,  both  in  epithelioma  and  in  carcinoma  and 
sarcoma  cases,  while  in  some  instances  it  is  recorded  that  it 
seemed  to  light  up  the  trouble  even  more.  Abundant  evidence 
exists,  however,  to  show  that  this  is  a  valuable  addition  to 
therapeusis,  as  has  been  seen  in  a  former  chapter. 

Of  late  years,  since  1910  and  to  the  present  time,  I  have 
treated  a  large  number  of  cases  of  cutaneous  epithelioma  with 
perfect  results  with  a  thorium  paste,  which  is  a  radio-active 
agent,  like  radium,  and  which  if  judiciously  used  is  capable  of 
effecting  wonders  in  the  treatment  of  many  cases  of  this  disease. 
It  is  somewhat  caustic  in  its  powers,  and  especially  until 
acquainted  fully  with  its  action,  it  should  be  employed  cau- 
tiously.    I  have  reported  twice  on  the  subject.1     The  paste  is 

'Buxkley,  "Notes  on  the  Technique  of  Using  Thoruim  Paste."  Chicago 
Medical  Recorder,  June  1913. 


CLINICAL  CONSIDERATIONS  AND  RESULTS  375 

now  called  the  Semerak  paste,  made  in  Chicago  after  directions 
by  the  originator,  and  obtained  through  the  drug  trade.  The 
formula  now  furnished  with  each  package  is  as  follows :  T^  Lead 
Sulphate  68.6,  Thorium  Sulphate  1.5,  Didymium  Sulphate, 
0.25  Sulphuric  Acid  (U.S. P.)  27.6,  Nitric  Acid,  trace,  and 
moisture  by  differences  2.05,  and  is  said  to  be  difficult  of 
production.  It  is  radio-active,  and  a  chemist  in  my  office,  on 
reading  the  formula  said  that  he  could  photograph  with  it, 
taking  of  course  a  long  time. 

It  is  difficult  to  give  briefly  the  technique  of  its  use,  which 
occupied  many  pages  in  my  reports,  but  a  few  hints  may  be  of 
service.  As  furnished  the  substance  is  too  acid,  and  I  pour  off 
that  which  rises  to  the  top,  and  even  use  the  paste  sometimes 
diluted  with  a  little  water;  to  raw  surfaces  the  latter  is  always 
wise.  In  an  early  epithelioma,  with  unbroken  skin,  the  paste 
may  be  used  in  full  strength,  treated  as  above,  applied  with  the 
glass  rod  furnished,  quite  over  all  the  surface,  and  left  to  dry  on ; 
where  there  is  danger  of  its  being  rubbed  off,  a  little  cotton 
may  be  applied,  when  it  is  dry,  and  plaster  over  it.  To  do  its 
full  work  this  crust  of  paste  should  remain  intact  for  a  week, 
but  after  five  days  an  application  of  olive  oil,  several  times  each 
day,  may  be  made,  to  facilitate  its  separation.  It  is  then 
removed  gently,  and  if  the  epithelioma  is  still  a  little  raised  a 
second  application  can  be  made,  and  again  at  a  week  or  10 
days  interval,  until  it  has  disappeared. 

The  crust  should  never  be  violently  torn  off,  but  if  there  is  any 
suppuration  beneath,  it  should  be  gently  removed  and  a  fresh 
application  made.  On  raw  surfaces  the  application  is  painful, 
and  sometimes  it  is  best  to  soak  the  surface  first  with  a  4  per 
cent  solution  of  cocain,  on  pledgets  of  absorbent  cotton,  before 
making  the  application.  In  real  raw  surfaces  it  is  sometimes 
well  to  treat  them  for  awhile  with  a  two  per  cent  watery  solution 
of  the  paste,  on  pledgets  of  absorbent  cotton,  during  the  day, 
and  the  application  at  night  of  a  rose  ointment  with  10  per 
cent  of  thorium  paste;  spread  on  cotton.  To  the  thickened 
edges  the  strong  paste  may  be  freely  applied. 


376  CANCER 

Finally,  some  cases  of  epithelioma  do  remarkably  well  with 
a  mild,  soothing  ointment,  spread  on  very  thin  layers  of  absor- 
bent cotton,  and  kept  on  continuously,  alternating  this,  perhaps, 
with  occasional  applications  of  the  Thorium  paste.  The 
ointment  which  I  commonly  use  is  as  follows:  R  Acid  Carbolic 
gr.  v,  Pulv.  Calamines  prep,  3t  Zinci  Oxidi  3ss  Unguent, 
aquae  rosae  5i  "HI- 

CANCER  OF  THE  BREAST 

Of  the  238  patients  with  cancer  in  the  breast,  of  which  three 
were  in  males,  one  primary  and  two  with  the  disease  recurrent 
after  operation;  one  of  these,  to  be  reported  later,  was  a  great 
sufferer  after  two  surgical  removals,  the  last  operation  being 
very  extensive,  with  a  greatly  swollen  arm.  Of  the  female 
cases  the  right  breast  was  affected  101  times,  the  left  breast  120 
times,  and  both  breasts  13  times,  and  4  not  recorded.  Among 
these  there  were  12  typical  cases  of  Paget's  disease. 

There  were  121  primary  cases,  that  is,  that  had  never  been 
submitted  to  surgical  removal,  though  many  had  had  #-ray 
and  radium.  Of  the  117  recurrent  cases  86  had  been  operated 
on  once,  20  twice,  four  3  times,  two  4  times,  and  one  5  times, 
with  a  continued  development  of  the  disease.  In  many  cases 
the  surgical  removal  had  been  done  almost  immediately  after 
the  first  discovery  of  the  lesion,  and  in  quite  a  number  of  these 
recurrences  were  observed  within  3  months  after  the  opera- 
tion. The  youngest  patient  was  single,  aged  26,  and  the  oldest 
85  years  old,  a  widow.  One  hundred  and  sixty-four  were 
married  or  widowed,  65  single,  and  nine  unrecorded. 

Some  few  of  the  patients  with  primary  carcinoma  have  come 
under  medical  treatment  within  a  few  days  after  the  first  dis- 
covery of  the  tumor,  when,  of  course,  there  is  the  best  chance  for 
its  dissipation;  but  unfortunately  many  patients  come  only  when 
other  measures,  surgery,  x-ray,  radium,  etc.  have  been  exhausted, 
or  when  the  disease  has  increased  so  greatly,  with  extensive 
adenopathy  that  the  case  has  been  pronounced  by  competent 
surgeons  to   be  wholly  inoperable  and    hopeless.     Of  the  89 


CLINICAL  CONSIDERATIONS  AND  RESULTS  377 

cases  of  cancer  of  the  breast  recorded  since  the  last  report  11 
are  known  to  have  died,  although  there  must  have  been  very 
many  more,  as  many  of  those  seen  only  once  or  twice  or  in 
consultation  were  very  far  advanced,  and  must  have  succumbed 
soon.  There  were  four  known  deaths  among  the  primary 
cases,  aged  85,  68,  53,  and  36,  all  far  advanced  and  inoperable. 
The  youngest  patient  in  this  series  was  25  years  of  age,  the 
oldest  85;  18  were  40  or  less  years  of  age,  and  the  average  was 
45K  years. 

It  is  a  little  disappointing  that  so  many  patients,  49,  were 
seen  but  once  or  twice  and  that  so  many  are  easily  discouraged 
by  the  common  belief  in  the  hopelessness  of  cancer  under  any 
treatment,  and  of  some  of  them  it  is  recorded  that  they  had 
been  persuaded  to  try  the  chances  of  a  surgical  operation.  But 
from  first  to  last  a  very  considerable  number,  some  dozens, 
have  been  faithful  and  persisted  in  treatment,  and  have  been 
very  grateful  for  the  results  obtained,  in  the  relief  from  pain 
without  an  opiate,  even  in  advanced  and  hopeless  cases.  Of 
the  patients  seen  since  the  last  full  report,  4  years  ago,  eight 
are  recorded  as  clinically  cured,  five  very  greatly  improved  and 
a  dozen  and  more  as  improved,  many  being  still  under  treat- 
ment. In  earlier  pages  there  were  a  considerable  number,  27, 
of  primary  cases,  some  of  these  were  reported  as  clinically  cured 
for  many  years:  Cases  I,  II,  III,  IV,  each  for  16  years,  others 
for  4  or  5  years,  or  greatly  improved  up  to  the  time  of  reporting, 
Cases  IX,  X,  XI,  XVIII,  XIX,  XX,  XXI,  XXII;  there  were 
also  n  cases  of  post-operative  cancer,  and  three  inoperable 
cases,  all  demonstrating  the  value  of  this  line  of  practice. 

Perhaps  enough  cases  have  already  been  presented  to  demon- 
strate conclusively  the  truth  of  the  position  taken  throughout 
this  book,  but  a  few  more,  from  among  many  others,  may  be 
given,  which  illustrate  features  not  previously  shown.  First 
may  be  mentioned  one  that  occurred  some  years  ago,  but 
which  was  earlier  overlooked. 

Case  XXXVII. — Primary  cancer  of  the  breast.  Mrs.  H.  R. 
aged  30,  had  been  under  my  care  for  acne  for  some  time,  when 


378  CANCER 

on  Oct.  26,  1904  she  called  my  attention  to  a  characteristic 
lump  about  an  inch  in  diameter  just  below  the  nipple  of  the 
right  breast,  for  which  she  had  consulted  her  family  physician 
in  September,  she  having  had  pain  in  it  since  July.  She  was 
a  nervous,  excitable  woman,  under  great  strain,  and  indulged 
a  good  deal  in  liquor,  and  ate  freely.  Not  being  willing  to 
have  the  operation  which  was  advised  by  her  physician,  she 
consulted  me  and  was  placed  on  diet  and  thorough  medical 
treatment.  To  be  brief,  on  December  27,  it  was  recorded  that 
there  was  no  pain  and  that  nothing  could  be  felt  in  the  breast, 
and  it  was  repeatedly  recorded,  for  several  months,  that  the 
breast  remained  normal.  She  is  a  difficult  patient  to  manage, 
living  high  at  times  and  neglecting  treatment,  and  has  been 
under  my  care  off  and  on  to  the  present  moment  for  various 
troubles,  over  16  years.  She  continually  has  high  blood  pres- 
sure, up  to  232  systolic  and  122  diastolic,  with  a  pulse  pressure 
of  no,  but  repeated  records  show  that  the  right  breast  remains 
normal. 

Once,  some  4  years  after  the  disappearance  of  the  mass  in 
the  right  breast,  she  had  a  tumor  develop  in  the  left  breast, 
which  also  subsided  under  careful  treatment,  and  both  breasts 
examined  recently  remain  perfectly  well.  She  has  never  been 
pregnant  and  still  has  her  menses,  at  47  years  of  age.  If  she 
relapses  into  her  former  mode  of  life  with  the  condition  of 
blood  arising  which  first  caused  the  right  breast,  to  be  affected, 
and  then,  after  some  years,  the  left  breast  to  be  attacked,  she 
will  probably  have  further  recurrences:  and  experience  teaches 
us  what  would  have  been  the  result  from  an  operation  over  16 
years  ago  when  the  disease  first  appeared. 

Case  XXXVIII. — Primary  cancer  of  the  breast.  Mrs.  K.  S. 
aged  28  came  for  treatment  Aug.  14,  1918,  with  a  hard  mass 
in  the  left  breast,  the  size  of  an  egg,  forming  for  some  months 
and  adhering  to  the  lower  side  of  the  nipple.  Some  lymph- 
nodes  were  found  in  the  pectoral  muscle  and  some  lumpy 
condition,  of  chronic  mastitis,  in  the  right  breast.  On  Decem- 
ber 16,  it  was  recorded  that  nothing  could  be  felt  in  the  left 


CLINICAL  CONSIDERATIONS  AND  RESULTS  379 

breast,  and  the  enlarged  glands  had  disappeared.  She  has 
been  under  constant  observation  and  treatment  from  the  first 
to  the  very  present  time,  and  remains  free  from  the  breast 
tumor,  though  she  has  a  little  caking  of  the  breast  occasionally 
at  the  time  of  the  menses,  which  are  regular.  She  has  never 
been  pregnant.  She  has  at  times  a  good  deal  of  rheumatism, 
so  common  in  these  cases.  Her  weight  which  was  97H  pounds 
when  first  seen  has  risen  to  103  lb.  She  has  been  under  con- 
stant dietetic  and  medical  treatment  now  for  over  2  years,  and 
if  she  continues  on  this  line  of  living  she  will  remain  free  from 
cancer,  as  have  the  others. 

Case  XXXIX. — Primary  cancer  of  the  breast.  Mrs.  C.  W. 
aged  40  first  seen  Apr.  18,  1919,.  never  pregnant,  regular  in 
menses,  had  noticed  a  soreness  in  the  right  breast  for  a  year, 
and  slowly  a  hard,  flat  mass  had  developed,  3  by  4  in.,  across 
the  middle.  Under  the  "green  card"  diet  and  the  acetate  of 
potassium  and  rumex  mixture  this  had  about  disappeared  when 
I  last  saw  her  Oct.  7,  19 19,  and  very  recently  her  husband 
reported  that  she  remained  perfectly  well. 

Case  XL. — Primary  cancer  of  the  breast.  Miss  M.  H.  N. 
aged  45,  had  removal  of  the  uterus,  for  what  was  called  a 
fibroid,  which  had  caused  menorrhagia,  in  February  19 19.  In 
June  1919  a  small  lump,  the  size  of  a  bean  had  appeared  in  the 
left  breast  which  had  disappeared  by  August,  under  some  treat- 
ment, not  surgical.  When  first  seen,  Mar.  20,  1920,  there  was 
in  the  left  breast,  directly  beneath  the  nipple,  a  moderately 
movable  mass  about  1%  inches  in  diameter,  with  one  freely 
movable  lymph-node  in  the  axilla.  Under  complete  treatment 
it  was  recorded  on  August  13,  that  there  was  no  trace  of  the 
trouble  in  the  breast,  nor  of  the  axillary  gland.  She  still 
maintains  the  diet  and  medicine,  and  recently  it  was  recorded, 
that  both  breasts  were  normal,  with  no  adenopathy. 

Case  XLI. — Primary  cancer  of  the  breast.  Mrs.  R.  R.  a 
short,  stout  woman,  aged  52,  had  noticed  a  small  lump  in  the 
right  breast  with  twinges  of  pain,  3  or  4  weeks  previous  to 
her  visit  on  Apr.  12,  1920,  which  a  doctor  had  tried  to  aspirate 


380  CANCER 

on  March  22,  and  gave  her  oil  to  be  rubbed  in.  When  seen 
there  was  a  hard,  rectangular  mass  3  by  4  inches  below  the  nipple. 
Under  diet  and  the  mixture,  with  capsules  of  thyroid,  5  gr. 
after  eating,  her  weight  which  was  something  over  170  lb.  at  first 
was  reduced  to  156^2.  On  October  14,  when  the  breast  trouble 
had  disappeared  she  said  that  she  "felt  fine,"  and  when  seen 
again  very  recently  the  breast  still  remained  normal.  Had  the 
breast  been  removed  surgically  there  would  certainly  have  been 
severe  recurrence  in  such  a  fat,  flabby  subject. 

The  oldest  patient  seen  presents  some  interesting  features. 

Case  XLII. — Primary  cancer  of  the  breast.  Mrs.  S.  aged  85, 
had  grip  2  years  ago,  after  which  a  small  lump  developed  in  the 
left  breast  pea-size  when  first  noticed.  This  increased  steadily 
in  size  and  she  was  treated  by  x-ray  for  over  a  year.  Radium 
was  then  once  used  for  4  hours.  When  first  seen  Sept.  26,  1918, 
there  was  a  large  mass  3  by  4  inches  in  the  center  of  the  left 
breast,  with  an  ulcerating  surface  an  inch  in  diameter,  just  above 
the  nipple,  giving  off  a  foul,  characteristic  odor.  As  she  lived 
some  distance  away  I  did  not  see  her  again,  but  heard  from  her 
physician  that  under  the  dietary  and  internal  and  local  treat- 
ment given  she  did  "remarkably  well."  While  there  was 
at  times  pain  she  was  up  and  did  much  knitting  for  the  sol- 
diers. She  died  suddenly  just  a  year  later,  without  the  disease 
having  made  any  progress. 

The  connection  between  diabetes  mellitus  and  cancer  has 
been  noted  by  several,  and  two  cases  were  observed  which  may 
be  briefly  mentioned.  They  are  particularly  interesting  in  the 
light  of  a  recent  article  by  Julius  Friedenwald1  on  "The  blood 
sugar  tolerance  test  as  an  aid  in  the  diagnosis  of  gastrointes- 
tinal cancer,"  although  relating  to  the  disease  in  another  locality. 
If  our  thesis  is  correct,  that  carcinoma  wherever  located  is  one 
and  the  same  disease  of  aberrant  epithelial  cells  from  constitu- 
tional causes,  and  if  the  evidence  which  he  has  collected  from 
literature  is  true  that  "hyperglycemia  is  always  present  in  can- 
cerous patients,"  this  may  afford  some  clue  to  the  disentangle- 

1  Friedenwald,  Amer.  Jour.  Med.  ScL,  September,  1920.     p.  313. 


CLINICAL  CONSIDERATIONS  AND  RESULTS  381 

merit  of  some  of  the  chemic  problems  connected  with  cancer. 
In  the  first  case  it  seemed  as  if  the  largely  carbonaceous  and 
saccharine  diet  which  did  wonders  for  the  carcinoma,  increased 
the  diabetes,  and  possibly  hastened  the  lethal  end. 

Case  XLIII. — Primary  cancer  of  both  breasts.  Mrs.  W.  C.  L. 
aged  40,  was  first  seen  Dec.  26,  1918.  Three  months  previous 
she  had  first  noticed  a  lump  in  the  right  breast  the  size  of  a 
marble,  which  grew  to  that  of  an  egg  in  one  month.  This  had 
since  decreased  almost  entirely  under  the  "green  card"  diet 
given  to  her  by  her  doctor.  Four  weeks  before  her  visit  a 
lump  appeared  in  the  left  breast,  which  had  steadily  increased. 
During  all  this  time  she  had  much  rheumatic  pain  over  the 
chest  and  arms,  she  having  had  two  attacks  of  acute  rheuma- 
tism, the  first  at  10  years  of  age.  She  had  always  been  a 
very  hearty  eater,  taking  much  meat,  and  had  eczema  for  15 
years;  rheumatism  and  eczema  being  not  uncommon  in  cancer- 
ous patients.  On  January  21,  it  was  recorded  that  the  mass  in 
the  right  breast  was  entirely  gone,  but  that  in  the  left  breast 
remained  about  the  same.  When  examined  on  March  13,  there 
was  absolutely  nothing  found  in  either  breast.  On  April  25,  I 
heard  from  her  physician  that  she  had  just  died,  very  suddenly 
of  diabetes,  and  from  the  person  who  made  the  autopsy  I 
learned  that  "there  was  no  evidence  of  malignant  disease 
found  in  the  viscera." 

Case  XLIV. — Post -operative  cancer  of  the  breast.  Mrs. 
F.  E.  L.  aged  62,  was  first  seen  Oct.  20,  191 7.  Two  years 
previously  she  had  noticed  a  small  lump  in  the  left  breast, 
which  was  removed  by  a  thorough  axillary  operation  the  same 
week,  microscopic  examination  showing  carcinoma.  In  July 
a  supra-clavicular  lymph-node  was  discovered,  which  was  at 
once  removed,  and  found  to  be  carcinomatous  microscopically. 
When  seen  there  were  again  glandular  nodes  over  the  left  clav- 
icle, and  a  small  one  in  the  left  axilla,  with  considerable  pain 
in  the  left  shoulder.  Under  the  largely  carbonaceous  diet  given 
she  developed  considerable  glycosuria,  for  which  she  had  been 
treated  abroad  before  the  war,  with  the  result  of  becoming 


382  CANCER 

and  remaining  sugar  free  when  she  came  under  my  observation 
and  treatment,  as  shown  by  several  urinalyses.  Her  saliva 
was  very  acid  and  remained  so  while  I  saw  her,  which  was  only 
for  a  month,  when  she  left  for  the  West,  somewhat  improved. 
In  August,  1920,  I  heard  that  she  had  recently  died,  possibly 
from  the  diabetes. 

Paget's  Disease  is  an  interesting  and  commonly  troublesome 
condition,  of  which  there  have  been  12  cases,  three  of  them  among 
the  last  series,  and  one  of  these  on  the  glans  penis. 

Case  XLV. — Paget's  disease  of  the  breast.  Mrs.  F.  T.  aged 
32,  had  had  a  slowly  developing  rawness  about  the  left  nipple, 
which  had  increased  steadily  for  a  year,  until  first  seen  October 
18,  1919.  There  was  then  a  characteristic,  circular,  red,  raw 
area,  something  over  an  inch  in  diameter,  moist  in  places  and 
glazed  in  others.  There  was  no  involvement  of  the  mammary 
gland  nor  axillary  adenopathy.  She  did  well  for  a  while,  so 
that  in  3  months  there  was  very  little  rawness,  and  some  areas 
of  good  epidermis.  There  was  still  no  evidence  of  deep 
carcinoma,  and  no  axillary  involvement.  But  at  the  end  of  5 
months  she  became  restless  and  saw  a  number  of  surgeons,  all 
of  whom  advised  radium  or  complete  ablation  of  the  breast, 
and  I  have  not  been  able  to  learn  the  result,  as  my  letter  has  not 
been  answered.  Another  case,  seen  at  the  same  time  is  worthy 
of  report. 

Case  XLVI. — Paget's  disease  of  the  breast.  Mrs.  I.  W.  J. 
aged  48,  came  to  me  Sept.  25,  1919.  For  about  2  years  she 
had  noticed  soreness  about  the  right  nipple,  with  rawness, 
which  had  gradually  increased,  until  when  first  seen  there  was 
an  area  affected  the  size  of  a  half-dollar.  It  was  a  little  raised, 
red  and  glazed  over.  There  was  no  deep  lump  in  the  breast, 
but  some  chronic  mastitis  in  the  left  breast,  no  axillary  adenop- 
athy on  either  side.  Under  dietetic  and  medicinal  treatment, 
including  thyroid,  and  the  continued  application  day  and  night, 
first  with  the  calamine  and  zinc  ointment,  already  referred  to, 
later  with  the  addition  to  it  of  half  of  one  drachm  of  ichthyol  to 
the  ounce,  the  lesion  soon  largely  subsided.     On  September  28, 


CLINICAL  CONSIDERATIONS  AND  RESULTS  383 

it  was  recorded,  that  the  breast  looked  better  than  ever,  with 
only  a  few  small  raw  points  and  the  days  before  there  had 
been  no  raw  points  on  removing  the  dressing;  the  chronic 
mastitis  in  the  left  breast  had  largely  disappeared;  no  axillary 
adenopathy  on  either  side. 

On  October  18,  as  there  was  still  a  little  rawness  in  places, 
and  she  was  restless,  and  wanted  radium,  this  was  applied  by  a 
colleague  with  a  patch  %  in.  square,  with  25  mg.  of  radium 
element,  in  shellac,  filtered  through  %  mm.  of  platinum,  for 
90  min.,  over  four  areas,  so  as  to  cover  the  entire  patch.  This 
applicator  had  been  used  effectively  in  many  various  conditions 
for  some  time,  and  the  result  was  a  perfect  healing,  with  only 
a  little  redness  and  no  rawness  at  all  for  over  4  months.  Seen 
recently  both  breasts  were  in  good  condition,  only  a  little  red, 
no  deep  lesion  and  no  adenopathy. 

Two  recent  cases  are  of  interest,  not  because  of  any  great 
advance  toward  a  cure,  but  from  the  remarkable  and  steady 
improvement  along  many  lines  which  has  taken  place  since 
beginning  treatment. 

Case  XL VII. — Advanced  primary  cancer  of  the  breast.  Miss 
B.  C.  M.  aged  52,  a  hard  working  and  ambitious  school  teacher, 
came  to  my  office  Sept.  14,  1920.  Three  years  ago  a  small  lump 
appeared  in  the  outer,  upper  segment  of  the  right  breast,  which 
had  been  treated  for  2  years  by  an  osteopath.  A  year  ago  it 
opened  spontaneously  and  a  surgeon  wished  to  remove  the 
whole  breast,  which  was  declined.  Since  then  the  mass  has 
increased,  with  active  and  deep  ulceration,  which  has  been 
treated  with  disinfectants,  but  with  no  other  measures. 

When  first  seen  the  whole  breast  was  hard,  presenting  a  deep, 
ulcerating  surface  of  about  2  by  3  inches  with  hard,  characteris- 
tic edges  and  profuse,  offensive  discharge.  There  were  several 
enlarged  axillary  glands,  somewhat  movable.  She  could  bear 
no  ordinary  clothing,  but  came  with  a  loose  wrap  over  the 
affected  breast.  She  was  depressed  and  anxious,  but  of  good 
color,  and  weighed  more  than  that  called  for  by  her  height  and 
age,  namely  160  pounds,  which  was  reduced  by  treatment  to  144 


3S4  CANCER 

when  seen  February  5.  She  had  always  been  constipated, 
and  had  piles  and  an  anal  fissure,  the  saliva  was  very  acid,  and 
the  sleep  very  bad  from  the  great  pain.  Being  placed  on  the 
acetate  and  rumex  mixture,  with  cascara,  and  very  strict  diet,  the 
change  recorded  in  2  weeks  was  remarkable:  she  slept  perfectly, 
with  no  pain,  no  opiate,  and  the  breast  appeared  better  and  the 
discharge  lessened,  and  soon  after  the  hardened  edges  flattened 
down,  with  signs  of  cicatrization  here  and  there.  She  was  given 
small  doses  of  thyroid  after  eating,  but  this  soon  disagreed  with 
her,  and  was  changed  to  5  grains  of  apiol  after  eating,  and  at 
bedtime,  and  from  time  to  time  she  has  had  various  remedies  to 
meet  digestive,  rheumatic,  nervous,  and  other  symptoms. 

The  change  in  her  whole  condition  from  the  first  to  her  last  re- 
cent visit  is  most  remarkable  in  comparison  with  the  previous  and 
usual  progress  in  such  cases.  She  now  dresses  as  usual,  is  very 
active,  walks  much,  going  upstairs  as  never  before,  going  out 
shopping  and  to  the  theatre  and  is  very  urgent  to  return  to  her 
school  duties,  from  which  she  has  been  absent  for  a  year  and  a 
half.  Her  color  and  appearance  are  excellent,  and  she  sleeps 
perfectly.  There  is  still  a  very  considerable  mass  in  the  breast, 
but  all  is  much  softer  and  the  ulceration  is  less  in  extent  and  not 
nearly  so  deep,  and  with  no  fetor.  From  first  to  last  she  has 
used  large  quantities  of  the  carbolized  calamine  and  zinc  oint- 
ment already  mentioned,  very  thickly  spread  on  thin  layers  of 
absorbent  cotton,  changed  twice  daily,  but  with  no  disinfectant, 
except  the  little  carbolic  acid  in  the  ointment.  When  last  seen 
April  19,  192 1,  over  7  months  after  her  first  call,  one  could 
hardly  believe  that  it  was  the  same  person,  well  dressed,  bright 
and  active,  without  a  particle  of  pain,  and,  as  her  sister  said, 
"wants  to  do  too  much." 

The  mass  still  exists  in  the  breast,  but  is  softer  and  has  dimin- 
ished markedly  in  size,  and  the  enlarged  axillary  glands  have 
about  disappeared.  While  the  disease  is  far  from  being  cured, 
and  will  require  yet  many  months  of  treatment,  there  is  reason 
to  hope  that  the  carcinosis  habit  or  dyscrasia  is  being  reached, 
and  with  faithful  and  intelligent  perseverance  the  disease  will  be 


CLINICAL  CONSIDERATIONS  AND  RESULTS  385 

overcome.  As  in  the  treatment  of  tuberculosis,  it  would  be 
unwise  to  allow  the  slighest  deviation  from  the  regime  which 
as  carried  her  thus  far  toward  health,  for  a  return  to  the  same 
conditions  which  caused  the  neoplasm  to  develop  would  prob- 
ably induce  a  recurrence. 

Case  XLVIII. — Post-operative  cancer,  both  breasts.  Mrs.  F. 
D.  J.  aged  48,  first  consulted  me  Nov.  6,  1920,  on  account  of  a 
mass  in  the  right  arm  which  developed  8  months  after  the 
removal  of  both  breasts  for  cancer.  This  mass  had  been  excised 
6  months  after  its  appearance,  but  soon  returned.  She  had  had 
trouble  with  the  left  breast,  called  mastitis  for  10  years,  and  in 
November,  19 16  a  bullet-like  lump  appeared,  and  the  breast 
became  larger  and  hard,  and  in  May,  19 18  both  breasts  were 
removed,  as  a  similar  condition  had  developed  in  the  right 
breast  shortly  before.  The  breast  lesions  were  determined 
microscopically  to  be  carcinomatous.  Since  the  last  operation 
she  had  had  much  pain  in  the  recurrent  mass  and  in  the  whole 
right  arm,  preventing  sleep.  She  had  been  on  the  "green  card" 
diet  for  some  time  before  consulting  me,  which  had  had  the 
effect  of  relieving  her  chronic  constipation  and  relieving  the 
pain  so  that  she  slept.  Being  placed  on  the  acetate  of  potassa, 
etc.  mixture  she  wrote  a  month  later  very  enthusiastically  that 
she  "had  been  more  comfortable  then  for  a  long  time,"  slept 
well  with  no  pain.  Her  last  letter  from  Los  Angeles,  Cal.,  Feb- 
ruary 23,  states  that  she  "has  not  been  so  well  for  many 
years." 

A  hospital  case,  which  well  illustrates  the  value  of  a  chemical 
removal  of  inoperable  breast  carcinoma,  instead  of  surgical 
excision,  is  worthy  of  report.  The  same  method  of  removal 
was  used  in  Case  XXIII,  already  reported. 

Case  XLIX. — Inoperable  cancer  of  the  breast,  with  chemical 
removal.  Mrs.  H.  L.  aged  46,  was  first  seen  Jan.  2,  1918.  She 
had  had  two  childern,  each  nursed  a  long  time,  and  there  was 
no  history  of  an  injury  or  of  mastitis.  Six  months  before  com- 
ing she  had  noticed  a  "hard  pimple"  by  the  nipple,  which  had 
remained  and  increased  in  size  pretty  rapidly  till  the  time  of  the 


386  CANCER 

visit.  When  first  seen  most  of  the  breast  was  involved  in  a 
hard,  scirrhous  mass,  with  deep  ulceration  and  hard,  very 
characteristic  everted  edges,  an  inch  and  a  half  or  more  in  dia- 
meter, with  axillary  adenopathy,  which  had  been  declared  en- 
tirely inoperable.  Being  placed  on  full  dietetic  and  medicinal 
treatment  it  was  soon  decided  that  the  mass  would  take  very 
long,  if  it  yielded  at  all  to  these  measures,  and  it  would  be  better 
if  it  could  be  removed. 

But,  as  for  a  long  time  I  had  not  consented  to  have  a  breast 
carcinoma  removed  by  the  knife,  I  decided  to  have  my  assist- 
ant Dr.  C.  W.  Strobel,  remove  it  by  caustic  or  chemical  extirpa- 
tion, which  he  had  been  practicing  for  many  years.  This  was 
done  on  January  25,  and  on  February  12  the  raw  surface,  level 
with  the  chest,  was  skin  grafted.  All  the  grafts  took  well,  and 
by  March  20  everything  was  closed  over  perfectly,  with  excellent 
result.  Leaving  the  hospital  she  was  watched  at  the  clinic  for 
some  months  and  on  October  23  was  recorded  that  the  scar 
was  excellent,  with  no  sign  of  recurrence  or  skin  nodules.  As  is 
so  often  the  case  she  became  irregular  in  calling,  and  in  diet  and 
medicine,  until  about  Jan.  2,  1921,  when  the  breast  area  was 
found  to  be  in  perfect  condition,  with  a  soft,  supple  scar,  but 
there  was  a  small  enlarged  gland  below  the  right-axilla.  She 
was  warned  of  the  danger,  and  has  been  faithful  to  internal 
dietetic  and  medicinal  measures  since,  and  on  April  13,  192 1,  it 
was  recorded  that  the  breast  area  was  perfect,  and  the  gland  had 
diminished  fully  one-half,  and  was  very  movable,  over  3  years 
after  the  chemical  removal.  When  we  consider  what  would 
have  been  the  result  of  the  rapidly  growing  and  deeply  ulcerating 
tumor  if  left  alone,  or  if  subjected  to  surgical  extirpation,  this 
result  is  extremely  satisfactory;  and  from  experience  it  may  be 
safely  predicted  that  with  continued  proper  care  the  gland  will 
disappear  and  she  will  ultimately  be  cured  of  her  disease. 

A  few  words  may  be  added  in  regard  to  this  safe  and  sane 
method  of  the  radical  removal  of  breast  carcinoma  by  chemical 
measures,  avoiding  the  mechanical  dissimination  of  the  disease 
which  is  so  common  in  surgical  procedures:  for  the  caustic 


CLINICAL  CONSIDERATIONS  AND  RESULTS  387 

seals  the  blood  and  lymph  vessels  as  the  destruction  of  the  tumor 
proceeds.  Thus  far  I  have  had  only  half  a  dozen  cases  thus 
treated,  but  Dr.  Strobel  claims  that  of  over  50  patients  he  has  so 
treated  there  has  not  been  recurrence  in  over  20  per  cent  of  the 
cases,  even  in  far  advanced,  broken  down  conditions,  for  I 
understand  that  all  his  cases  are  of  this  character.  I  see  no 
reason,  however,  why  it  is  not  equally  applicable  to  primary 
cases  where  there  is  an  urgent  desire  to  remove  the  offending 
tumor,  provided  thorough  dietetic  and  medicinal  treatment  is 
also  employed  for  a  long  time  to  remove  the  cause;  although 
I  have  shown  by  cases  that  these  latter  yield  perfectly  to  this 
internal  treatment  alone. 

The  technique  evolved  by  Dr.  Strobel  makes  this  procedure 
both  painless  and  thorough,  and  with  no  operative  dangers. 
The  anaesthetic  employed  almost  exclusively  is  by  the  hypoder- 
mic injection  of  a  tablet  of  scopolamine-morphine,  or  hyoscine- 
morphine  an  hour  before  the  operation  is  begun  and  again  half 
an  hour  later,  sometimes  a  whiff  of  an  inhalant  is  required  at 
the  beginning;  nothing  is  necessary  after  the  skin  is  all  removed, 
or  at  subsequent  applications  of  the  caustic  paste,  about  every 
other  day,  when  also  the  resulting  slough  is  trimmed  off. 

He  divides  the  operation  into  four  stages:  (1)  Denuding  the 
skin,  down  to  the  breast  tissue  with,  first  an  application  of 
carbolic  acid,  and  then  by  the  very  free  use  of  stick  caustic 
potash,  dampened  frequently.  (2)  The  caustic  paste  of  chloride 
of  zinc  and  flour,  equal  parts,  and  water,  darkened  with  pow- 
dered charcoal,  spread  on  canton  flannel,  cut  in  pieces  to  fit,  is 
laid  over  the  whole  denuded  area.  As  this  is  removed  about 
every  other  day  there  is  a  slough  which  is  trimmed  off,  and  a  new 
application  made.  As  I  have  repeatedly  witnessed  this  pro- 
cedure the  patients  say  there  is  no  pain.  (3)  When  the  chest 
level  is  reached,  generally  within  2  weeks,  there  is  a  large  area, 
with  reddened,  inflammatory  edges,  and  an  adherent  slough, 
which  is  kept  covered  with  an  emollient  ointment,  spread  on 
lint,  changed  several  times  daily,  until  it  is  shed,  and  a  raw, 
healthy,  granulation  surface  is  presented.     (4)  This  is  then  skin- 


388  CANCER 

grafted  thoroughly  and  properly  cared  for.  Great  care  must 
be  exercised  in  confining  the  chloride  of  zinc  paste  to  the  area 
to  be  destroyed,  by  proper  protection  and  careful  nursing,  for 
there  is  pain  indeed  if  it  gets  on  the  skin,  which  is  the  reason  for 
darkening  it  with  charcoal. 

This  method  of  removal  of  a  cancerous  breast  seems  to  be 
the  most  rational  possible,  when  combined  with  thorough  and 
intensive  internal  measures  to  prevent  the  further  development 
of  the  products  of  the  carcinosis  in  other  places.  For  there  is 
certainly  not  the  recurrence  seen  about  the  healed  surface 
which  commonly  appears  after  surgical  procedures,  nor  the 
swollen  arms,  so  frequently  resulting  from  the  latter,  and,  of 
course,  no  operative  mortality.  When  there  is  already  much 
involvement  of  the  axillary  or  supra-clavicular  or  other  glands 
there  is,  of  course  danger,  of  a  fresh  outbreak  or  development 
of  the  products  of  the  disease  somewhere  else.  But  when  there 
is  only  slight  axillary  involvement  the  gland,  or  few  glands, 
they  can  be  destroyed  and  enucleated  by  the  very  careful 
use  of  the  caustic  stick  potash,  while  the  employment  of  any 
cutting  instrument  vitiates  the  whole  proceeding,  and  invites 
recurrence. 

Case  XLIX. — Post-operative  cancer  of  the  male  breast.  Dr. 
G.  J.  aged  41,  first  seen  Oct.  20,  1919.  Twenty  seven  months 
previously  he  began  to  have  a  tense,  inflammatory  condition 
of  both  nipples,  and  the  right  one  began  to  discharge.  In 
October  1917,  the  right  breast  was  excised,  but  not  the  axil- 
lary contents.  Six  months  ago  he  noticed  the  axillary  glands 
enlarged,  and  then  he  had  a  very  extensive  operation  in  New 
York.  Shortly  there  again  appeared  axillary  lumps,  and 
cutaneous  manifestations.  When  seen  there  was  an  enormous, 
elliptical  scar  from  the  neck,  along  the  clavicle,  to  the  arm, 
across  the  axilla  and  down  the  chest  to  the  abdomen.  All 
around  the  scar  on  the  chest  were  very  numerous  cutaneous 
nodules,  and  the  arm  was  hard  and  greatly  swollen,  15  in. 
in  circumference  compared  to  11^  of  the  other  arm.  The 
saliva  was  very  acid.     He  had  had  #-ray  and  radium  treatment 


CLINICAL  CONSIDERATIONS  AND  RESULTS  389 

for  the  past  6  months,  with  no  relief  to  the  great  pain  in  the 
arm,  which  prevented  sleep.  He  was  soon  lost  sight  of  and 
nothing  has  been  learned  as  to  the  result  of  the  treatment 

advised. 

CANCER  OF  THE  UTERUS 

There  were  22  cases  of  cancer  of  the  uterus  and  vagina  and 
one  of  the  ovary;  the  latter  patient  had  been  submitted  to  an 
operation,  when  two  large  cysts  were  found,  undergoing 
malignant  change,  with  involvement  of  the  lower  bowel  and 
rectum.  Almost  all  of  the  cases  were  post-operative,  or  had 
been  submitted  to  curetting,  caustics,  #-ray,  radium,  etc. 
There  were  recently  6  primary  cases  which  had  been  declared 
entirely  unoperable,  each  by  several  surgeons,  in  three  of  which 
the  results  of  treatment  were  remarkable,  to  be  mentioned 
later.  Only  one  or  two  of  them  had  not  been  previously  treated 
actively,  and  one  of  these,  a  recent  case,  has  shown  great 
improvement  in  three  months.  The  ages  of  these  patients 
ran  from  33  to  77  years  of  age,  and  there  were  five  of  40  or  less 
years,  the  average  age  being  50  years. 

Ten  of  the  patients  were  seen  only  once  or  twice  or  in  con- 
sultation, four  or  five  of  the  entire  number  are  known  to  have 
died,  although  there  were  probably  many  more,  and  three  are 
clinically  cured,  while  others  have  been  materially  benefitted. 
The  two  totally  inoperable  cases,  XV  and  XVI  reported  2 
years  ago  are  still  living  and  well,  fully  5  years  after  adopting 
this  line  of  treatment,  and  another  similar  case,  more  remarkable 
will  be  recorded. 

Case  LI. — Inoperable  cancer  of  the  uterus.  Mrs.  W.  G.  aged 
43/12  came  on  Feb.  6,  1919,  hardly  able  to  crawl  up  the  single 
flight  of  stairs  to  my  office,  so  great  was  her  pain.  For  3  years 
she  had  felt  badly,  with  an  uneasy  pain  toward  the  pubis, 
keeping  her  awake  at  night.  In  June,  1918,  she  had  increased 
vaginal  discharge,  until  curetted  on  October.  In  October  she 
saw  four  surgeons  in  another  city,  one  of  them  very  prominent, 
all  of  whom  diagnosed  inoperable  cancer,  and  she  was  given  not 
6  months  to  five,  on  morphine,  and  told  that  there  was  no 

25 


390  CANCER 

possible  treatment,  medical  or  other,  which  could  possibly 
help  her.  On  November  15,  she  went  to  an  advertising  cancer 
sanitarium  for  6  weeks  and  had  various  treatments.  On 
January  20,  she  went  to  a  New  York  Hospital,  where  explora- 
tory cceliotomy  was  performed,  by  a  well  known  surgeon,  who 
found  "the  uterus  hard  and  adherent  to  the  pelvis,  the  ureters 
and  bladder  involved,  and  masses  of  glands  in  the  floor  of  the 
pelvis,  absolutely  inoperable,"  and  was  given  not  2  months  to 
live. 

When  first  seen  there  was  a  great  and  very  offensive  vaginal 
discharge,  with  intense  backache  and  continual  abdominal 
pain.  She  was  a  good  deal  over  weight  for  her  height  and  age, 
flabby,  always  constipated,  the  urine  very  deficient  in  solid 
constituents,  and  the  saliva  very  acid. 

Being  placed  on  the  "green  card"  diet,  with  acetate  of 
potasa,  nux,  cascara,  and  rumex  mixture,  and  douches  of  a 
pint  of  very  hot  water  with  carbolic  and  sodium  biborate  night 
and  morning,  as  previously  mentioned,  in  8  days  she  stated 
that  she  "felt  like  a  different  woman,"  the  backache  was  much 
better,  and  the  douche  came  away  still  cloudy,  but  without 
odor.  One  month  from  the  first  visit  she  stated  that  she  "felt 
better  than  in  2  years,"  slept  perfectly  from  10  to  6:30.  On 
April  25,  it  was  recorded  that  for  2  weeks  she  had  felt  absolutely 
well,  "never  felt  so  well  in  her  life,"  "not  an  ache  or  a  pain,  and 
had  sometimes  walked  for  miles."  The  urine  had  been  brought 
up  in  its  solid  constituants  to  about  normal,  by  the  use  of 
caffein,  2  gr.  after  each  meal,  while  continuing  the  former 
mixture,  and  on  May  23,  it  was  recorded  that  she  "would  never 
know  that  she  had  been  sick." 

On  Mar.  26,  1920,  I  sent  her  to  the  surgeon  who  had  per- 
formed the  exploratory  cceliotomy,  14  months  previously,  and 
had  given  her  2  months  to  live,  and  he  was  naturally  amazed, 
and  could  hardly  believe  that  she  was  the  same  patient,  and 
said  "you  look  like  a  perfectly  healthly  woman."  Strange  to 
say,  the  menses,  which  had  been  absent  for  2  years,  appeared 
on  that  date  quite  normally,  ceasing  after  3  or  4  days,  and  then 


CLINICAL  CONSIDERATIONS  AND  RESULTS  391 

recurred  each  month,  or  in  28  days,  in  the  same  manner. 
During  this  year  and  a  half  she  had  naturally  required  various 
remedies  to  meet  different  conditions,  which  need  not  be 
detailed  here.  She  neither  required  or  took  a  particle  of 
morphine  nor  any  hypnotic  during  the  entire  period,  18  months 
after  her  first  visit. 

A  rather  recent  case  is  also  of  considerable  interest,  because 
of  the  previous  history  and  the  unusual  and  steady  gain  in 
8  months. 

Case  LII. — Inoperable  cancer  of  the  uterus.  Mrs.  G.  N. 
aged  40,  first  came  under  my  care  July  13,  1920.  Five  and  a 
half  years  before  she  had  uterine  hemorrhage  for  2  months. 
This  was  actively  treated  by  packing  and  remedies,  until 
Nov.  22,  1916,  when  the  uterus  was  removed  by  a  very  good 
operator.  After  this  she  was  pretty  well  for  a  time,  but  with 
much  sickness  in  the  family,  and  worry,  and  trouble  with  the  urine 
she  was  much  depressed,  and  on  Nov.  24,  19 19  went  to  the  same 
Hospital,  when  there  was  found  so  much  return  of  the  disease 
that  she  was  considered  inoperable  and  was  sent  to  the 
Memorial  hospital  for  radium  treatment.  There  she  had  three 
treatments,  but  in  June  it  was  given  up  as  hopeless.  Being 
placed  under  strict  dietary  and  therapeutic  measures,  with  a 
douche  two  or  three  times  daily  she  improved  steadily,  so 
that  the  douche  came  away  about  clear,  the  pains  had  about 
gone.  Being  asked  to  return  for  examination  to  the  Memorial 
about  February  15,  the  physician  there  was  greatly  surprised 
to  see  her  so  well,  as  he  had  expected  her  decease  long  before, 
and  he  found  a  hard  patch  on  the  side  of  the  vagina,  for  which 
he  wished  to  use  radium  again,  which  she  refused.  She  had 
neglected  the  treatment  more  or  less,  and  was  again  constipated 
and  when  last  seen  Mar.  12,  192 1,  she  complained  of  much 
pain  in  the  right  hip,  possibly  from  bone  metastasis,  and  again 
had  some  bloody  discharge.  But  the  improvement  in  her 
general  condition,  with  gain  in  flesh  and  color  in  these  eight 
months  warrants  the  belief  that  if  she  remains  perfectly  faithful 
to  treatment  the  disease  will  be  overcome,  as  in  the  other  cases. 


392  CANCER 

CANCER  OF  THE  LIP 

Thirty-eight  cases  of  cancer  of  lip  were  recorded,  35  in  males 
and  three  in  females:  all  the  latter  were  on  the  upper  lip, 
and  mainly  on  the  cutaneous  portion,  also  two  of  the  males, 
all  the  other  cases  in  males  were  on  the  lower  lip.  Fourteen 
patients  were  seen  only  once  or  twice  or  in  consultation,  leaving 
21  cases  more  or  less  satisfactorily  treated,  although  some 
dropped  off  or  were  lost  sight  of  too  soon  to  form  any  definite 
judgment  concerning  them.  Of  these  21  cases,  nine  were 
recorded  as  clinically  cured,  four  greatly  improved,  eight 
improved.  Two  were  known  to  have  died,  one  from  apoplexy 
and  one  from  hemorrhage  from  secondary  infection  in  the  neck. 
It  is  fair  to  say  that  most  of  the  cases  were  in  a  pretty  early, 
although  perfectly  characteristic  stage,  with  lesions  of  not  over 
half  or  three  quarters  of  an  inch  in  diameter,  and  there  were 
none  of  the  terrible  late  cases  sometimes  seen.  The  location 
of  the  lesions  in  men  were  14  on  the  right  side  of  the  lip,  9  on 
the  left,  nine  in  the  middle,  and  in  three  instances  it  was  not 
recorded.  Most  of  the  patients  were  smokers,  some  used  the 
pipe,  but  some  neither  smoked  nor  used  alcoholics.  Two 
striking  cases  XXXV  and  XXXVI,  have  been  given  to  show 
that,  in  the  early  stage,  at  least,  the  disease  is  amenable  to 
correct  medical  treatment,  when  faithfully  carried  out;  earlier 
cauterization,  as  with  nitrate  of  silver,  makes  this  more  difficult. 

CANCER  OF  THE  TONGUE  AND  MOUTH 

Forty-seven  cases  appear  here,  tongue  16,  buccal  cavity  11, 
serious  affection  of  the  jaw  17,  soft  palate,  tonsil,  and  larynx 
each  one.  Of  the  entire  number  30  were  seen  only  one  or  two 
times,  or  in  consultation.  There  were  only  six  females  in  the 
whole  47.  The  ages  ran  from  28,  a  lady  with  a  serious  cancer 
of  the  tongue  whose  case  will  be  detailed  later,  to  76  years  of 
age.  There  were  but  four  who  were  40  years  of  age  or  less,  and 
10  who  were  70  or  over  and  the  average  of  all  was  57  years. 

The  end  results  of   cancer  within   the  mouth   are  indeed 


CLINICAL  CONSIDERATIONS  AND  RESULTS  393 

distressing  and  show  the  impotence  of  our  present  means  of 
reaching  the  disease  by  local  measures,  and  the  futility  of 
surgical  procedures  in  this  location.  Almost  all  the  patients 
had  been  subjected  to  active  treatment  by  surgery,  #-ray, 
radium,  caustics,  or  curetting,  and  many  of  them  were  in  a 
pitiable  condition  when  first  seen.  Ten  were  known  or  believed 
to  have  died  but  there  must  have  been  many  more,  and  but 
two  of  the  entire  number  are  recorded  as  cured,  and  these  were 
tongue  cases.  The  total  amount  of  misery  and  suffering  from 
cancer  in  this  locality  seems  to  exceed  the  total  experienced  by 
an  equal  number  of  patients  with  cancer  in  any  other  locality, 
although  post-operative  cancer  of  the  breast  and  uterus  is 
often  painful  beyond  measure,  in  many  cases.  The  enormous 
and  deep  lymphatic  supply  and  connections,  with  their  early 
and  almost  certain  involvement,  preclude  the  expectation  of 
benefit  from  surgical  attempts  to  check  the  disease.  Good 
results  have  been  claimed  for  radium  and  thermo-therapy  within 
the  mouth,  and  experience  would  seem  to  show  that  the  knife 
and  caustics  do  more  harm  than  good  in  this  region  of  the  body. 
But  very  careful  and  proper  dietary  and  medical  treatment, 
general  and  local  have  been  productive  of  good  results  to  many 
patients,  both  in  lengthening  life  and  relieving  pain,  and 
many  cases  have  records  of  improvement,  and  some  of  great 
improvement,  although  naturally  but  few  are  recorded  as 
clinically  cured;  this  is  not  surprising  or  discouraging,  consider- 
ing the  generally  hopeless  condition  of  these  patients  when 
first  seen,  commonly  in  a  late  stage,  and  their  distressing  end: 
some  illustrations  will  be  given. 

CANCER  OF  THE  TONGUE 

Sixteen  cases  of  cancer  of  the  tongue  were  recorded,  but  of 
these  eight  were  seen  only  once  or  twice,  or  in  consultation.  Of 
the  cases  treated  two  were  clinically  cured,  one  was  known  to 
have  died,  and  four  probably  succumed,  so  great  was  amount  of 
disease  when  last  seen.  The  ages  ran  from  28  (the  only  one 
under  40)  to  75  years,  the  average  of  all  being  just  57 :  there  were 


394  CANCER 

four  females  and  1 2  males.  The  disease  was  located  on  the  right 
side  in  12  cases,  on  the  left  in  three,  and  in  the  middle  in  one. 
In  several  the  disease  had  lasted  2  years,  and  the  most  recent 
case  was  of  2  months  duration.  One  interesting  and  fatal 
case  who  at  first  did  marvellously  well,  with  the  greatest  relief 
to  an  enormously  affected  tongue,  but  who  finally  sucumbed, 
has  been  already  reported,  Case  XXXIII.  The  good  results 
of  gentle  and  properly  directed  medical  measures,  when  the 
case  is  seen  fairly  early  are  well  shown  in  the  following  case. 

Case  LIII. — Early  cancer  of  the  tongue.  Miss  B.  S.  E. 
aged  75,  had  been  under  my  care  for  chronic  eczema,  some 
years  before  she  was  sent  to  me  by  her  physician  on  Mar.  15, 
1919,  on  account  of  a  trouble  on  the  tongue,  which  he  rightly 
recognized  as  early  cancer.  Two  months  previous  she  had 
felt  an  irritation  on  the  right  side  of  the  tongue,  which  was 
treated  2  weeks  with  nitrate  of  silver,  and  as  a  painful  ulcer 
formed,  she  was  using  an  application  of  cocaine  and  boric  acid. 
She  had  long  been  constipated  but  used  remedies,  the  tongue 
was  much  coated,  the  saliva  neutral;  she  was  drowsy  during 
the  day  time,  and  had  lost  some  weight,  it  being  then  135^  lb. 

When  first  seen  there  was  a  painful  ulcerated  lesion  about  the 
middle  of  the  right  side  of  the  tongue,  nearly  the  size  of  a  quarter, 
edges  moderately  hard,  and  with  some  adenopathy  under  the 
right  jaw.  Being  placed  on  full  dietetic  and  medical  treatment, 
with  a  mouth  wash  of  saturated  solution  of  bicarbonate  soda, 
diluted  if  necessary,  and  used  very  thoroughly  34  nr-  before 
and  y^  hr.  after  eating,  it  is  recorded  that  there  was  decided 
improvement  in  10  days.  The  area  had  cleared  off  and  was 
less  hard,  and  the  pain  had  decreased.  By  May  27,  it  was 
recorded  that  the  tongue  seemed  well,  there  being  no  hardness 
and  no  glandular  enlargement  could  be  felt.  From  that  time  to 
the  present  the  tongue  has  remained  practically  well,  although 
she  has  repeatedly  had  apthous  sores  in  various  places,  which 
have  yielded  to  careful  medication,  and  occasionally  the  original 
site  seems  to  light  up,  but  never  to  harden  or  ulcerate.  Seen 
by  Dr.  Janeway  that  summer  he  confirmed  the  diagnosis  and 


CLINICAL  CONSIDERATIONS  AND  RESULTS  395 

remarked  upon  the  satisfactory  control  of  the  disease.  For 
a  long  time  there  remained  a  somewhat  raised,  reddened  area 
in  the  old  site,  but  never  anything  like  ulceration.  She  has  had 
quite  a  good  deal  of  other  sickness,  much  of  it  rheumatic  in 
character,  but  when  seen  Aug.  22,  1920,  there  was  no  trace  of 
the  former  trouble.  She  has  adhered  more  or  less  to  the  diet 
and  medication. 

This  is  a  good  illustration  of  the  harmfulness  of  nitrate  of 
silver  in  driving  an  innocent  lesion  on  the  tongue  into  a  malig- 
nant one,  and  had  there  been  a  surgical  operation  at  first,  and 
a  continued  neglect  of  proper  dietary  and  internal  treatment, 
the  course  would  probably  have  been  such  as  is  continually 
seen  in  these  sad  cases,  such  as  Case  XXXIII. 

In  the  following  case  there  was  no  history  of  cauterization, 
but  the  disease  was  far  advanced  when  first  seen  and  proved 
more  rebellious. 

Case  LIV. — Inoperable  cancer  of  the  tongue.  Mr.  P.  E., 
aged  49,  seen  first  Jan.  27,  19 19.  For  15  years  he  had  had 
white  patches  on  the  left  side  of  the  tongue,  and  5  years  prior 
to  his  visit  there  were  small  ulcers  within  the  cheek.  Five 
months  before  he  came  the  white  patches  on  the  left  side  of  the 
tongue  broke  down  and  became  ulcerated  and  bleeding;  the 
whole  thing  was  not  painful  to  any  degree,  but  occasionally 
he  had  pain  beneath  the  jaw.  His  Wasserman  had  been  found 
negative,  he  had  never  smoked  much. 

When  first  seen  there  was  a  new  growth,  nearly  3  by  1  inch, 
on  the  left  side  of  the  tongue,  moderately  hard,  presenting  a 
roughened,  fungating  surface,  with  fissures,  and  some  glandular 
enlargement  beneath  the  jaw,  utterly  inoperable.  Being  on 
complete  dietary  and  other  treatment,  with  the  bicarbonate  of 
soda  mouth  wash  six  times  daily,  on  March  17,  it  was  recorded 
that  he  felt  very  different,  the  saliva,  which  was  very  acid  at 
first  became  neutral,  he  lost  the  pain  in  the  tongue  and  side  of 
the  head,  the  ulcer  had  somewhat  healed,  the  fissure  was  not 
one-half  the  size,  and  the  glands  beneath  the  jaw  were  decidedly 
smaller.     By  Oct.  25,  he  noticed  that  the  tongue  was  softer, 


396  CANCER 

though  occasionally  it  bled  some,  and  hardly  any  glands  could 
be  felt  beneath  the  jaw.  On  Jan.  24,  1920,  1  year  from  the  first, 
it  was  recorded  that  the  diseased  mass  had  shrunken  considerably 
in  contrast  to  the  first  condition,  but  that  there  was  some  lym- 
phatic involvement  in  the  left  side  of  the  neck.  On  Mar.  20, 
it  was  recorded  that  there  was  still  much  hardness  of  the 
tongue,  and  not  much  pain,  but  he  had  a  great  flow  of  saliva, 
which,  however,  was  neutral  or  even  a  little  alkaline.  A 
little  later  there  was  great  swelling  and  tenderness  on  the  left 
side  of  the  face  and  beneath  the  jaw,  and  still  later  much  red- 
ness over  all  the  neck,  but  the  tongue  remained  in  much  the 
same  fair  condition.  He  was  then  having  piles  and  passing 
blood  from  them,  and  unfortunately  he  was  then  lost  sight  of. 
But  the  relief  and  benefit  which  he  obtained  during  the  14 
months  he  was  under  full  dietetic  and  medical  treatment  was 
very  great,  for  which  he  was  very  grateful. 

There  have  been  several  other  more  or  less  similar  cases.  One 
of  these  may  be  narrated  to  illustrate  the  evil  result  of  early 
bad  treatment,  scraping  or  cutting,  leading  to  infection  of  deep 
lymphatics,  which  caused  a  fatal  termination  8  months  after 
she  was  first  seen,  in  spite  of  very  great  improvement  in  the 
disease  on  the  tongue  while  under  treatment. 

Case  LV. — Advanced  cancer  of  the  tongue.  Mrs.  S.  E.  aged 
28,  first  seen  on  Mar.  18,  1913.  Something  over  2  years 
previously  there  was  an  irritation  on  the  right  side  of  the  tongue, 
possibly  from  a  rough  tooth,  and  about  a  year  later  the  left 
side  of  the  tongue  was  affected.  The  right  side  of  the  tongue 
was  scraped  and  burned  soon  after  it  first  became  affected  and 
it  had  remained  increasingly  sore  ever  since.  Five  or  six 
weeks  before  her  visit  she  entered  one  of  the  New  York 
Hospitals  where  a  negative  Wasserman  was  taken,  and  a  sec- 
tion made  from  the  right  side  of  the  tongue,  with  the  report  of 
epithelioma. 

When  first  seen  a  ragged  ulcer  extending  from  near  the  tip 
to  the  base  of  the  tongue,  on  the  right  side,  with  slightly  en- 
larged glands:  there  was  a  little  trouble  on  the  left  side.     She 


CLINICAL  CONSIDERATIONS  AND  RESULTS  397 

had  always  been  constipated  and  was  dyspeptic,  and   lately 
had  bad  sleep,  and  was  taking  aspirin  and  codein. 

Being  placed  on  a  strict  dietetic  and  medicinal  regime,  with  a 
weak  mouth  wash  with  carbolic,  salicylic  acid,  borax,  and 
honey,  it  was  recorded  on  Apr.  8  that  there  was  a  "remarkable 
change."  The  sore  on  the  right  side  had  diminished  largely, 
and  the  pain  had  about  gone.  On  May  8  it  was  recorded  that 
the  sore  on  the  right  side  of  the  tongue  was  largely  healed, 
though  there  was  still  hardness,  and  there  was  very  little 
adenopathy.  On  May  22  it  was  recorded  that  the  right  side 
of  the  tongue  was  almost  healed,  on  the  left  side  there  was  still 
some  ulceration,  but  not  painful  on  handling.  She  then  took  a 
trip  West  and  neglected  treatment  and  was  very  constipated, 
and  on  June  22  it  was  recorded  that  there  was  a  lump  in  the 
side  of  the  throat  nearly  choking  her,  and  that  she  could  not 
sleep  from  the  great  pain  and  burning  in  the  tongue.  On 
examination  there  was  found  sloughing,  the  left  tonsil  excavated 
with  a  foul  smelling  discharge,  and  on  the  left  side  of  the  neck 
large  hard,  fixed  lymph  nodes.  Four  days  later  she  had  a  very 
severe  hemorrhage  from  the  spot  where  the  tissue  was  cut  for 
examination.  Four  days  still  later  there  was  a  severe  cough, 
showing  lung  involvement.  She  was  not  seen  then  until 
Nov.  2,  when  whole  neck  was  hard  and  board  like;  she  was 
greatly  emaciated,  pulse  140  and  died  5  days  later,  the  victim 
of  curetting  and  biopsy  for  evident  cancer. 

CANCER  OF  THE  BUCCAL  CAVITY 

Carcinoma  within  the  mouth  is  always  a  sad  and  discouraging 
proposition,  for,  unless  taken  very  early  and  treated  very  wisely, 
there  is  commonly  a  steady  progress  with  deep  glandular  in- 
volvement, which  renders  a  permanent  cure  almost  hopeless; 
though  of  late  great  claims,  for  temporary  benefit  at  least, 
have  been  made  for  radium  and  thermo-therapy,  as  mentioned 
in  another  chapter.  But  the  end  results  of  this  treatment  are 
as  yet  unknown.  Surgery,  it  would  seem  from  experience  is 
helpless  if  not  harmful. 


398  CANCER 

There  were  31  cases  recorded,  17  in  the  jaw,  all  males,  11  in 
the  cheek  or  floor  of  the  mouth,  one  female,  one  on  the  soft 
palate,  one  on  the  tonsil  and  one  in  the  larynx,  all  males. 

CANCER  OF  THE  JAW 

Of  the  17  cases  of  cancer  of  the  jaw,  one  female,  the  disease 
affected  the  upper  jaw  in  three  patients,  and  all  were  on  the 
right  side,  except  two  on  the  left.  The  recognized  duration  of 
the  disease  had  been  from  3  weeks,  in  a  gentleman  aged  65,  to 
be  reported,  generally  from  a  few  months,  to  some  years, 
even,  16,  as  in  case  64  also  to  be  reported. 

Case  LVI. — Mr.  G.  E.  aged  75  noticed  a  mass  on  the  left 
side  of  the  lower  jaw  3  weeks  before  his  visit,  which  had  shortly 
ulcerated.  When  seen  Jan.  15,  19 15  there  was  a  mass  %  inch 
in  diameter,  adherent  to  the  bone  and  involving  the  sulcus  of 
the  cheek,  with  a  typically  carcinomatous  ulceration  and  en- 
larged lymph  glands  in  the  neck.  Under  active  treatment,  with 
the  mouth  wash  already  mentioned  there  was  almost  at  once  a 
surprising  improvement  and  within  a  month  the  mass  had 
largely  subsided  and  healed,  with  very  little  swelling  of  the 
jaw  or  adenopathy.  Shortly  after  this  he  wrote  me  that  the 
trouble  was  so  nearly  well  that  he  would  not  call,  as  appointed, 
promising  to  come  if  any  unfavorable  symptoms  developed.  I 
wrote  for  him  not  to  neglect  treatment,  and  as  he  was  a  very 
intelligent  man  I  cannot  but  believe  that  the  disease  was 
checked  in  its  incipiency. 

Case  LVII. — Inoperable  cancer  of  lower  jaw.  Mr.  E.  G.,  aged 
70,  seen  first  on  Jan.  2,  1919,  lived  until  Apr.  11,  1920  with  an 
enormous  amount  of  malignant  disease  of  the  front  of  the  lower 
jaw,  which  when  first  seen  threatened  to  carry  him  off  shortly. 
For  some  months  he  seemed  to  be  doing  excellently  well,  and 
it  was  recorded  on  Feb.  1,  that  there  was  steady  and  great 
improvement  and  very  little  pain  or  trouble,  he  finding  great 
relief  from  aspirin  freely  given.  Also  on  July  24,  the  mass  was 
smaller,  and  he  appeared  better  in  every  way.  He  lived  some 
distance  from  the  city,  and  was  probably  not  very  attentive  to 


CLINICAL  CONSIDERATIONS  AND  RESULTS  399 

all  the  details  of  treatment,  and  soon  began  to  take  morphine, 
though  in  moderate  quantity,  until  he  died  Apr.  n,  1920,  15 
months  after  his  first  visit.  After  he  began  to  take  morphine 
the  disease  increased  and  progressed  rapidly. 

CANCER  OF  THE  MOUTH 

Of  the  1 1  patients  with  cancer  of  the  soft  tissues  of  the  mouth 
there  was  one  female,  aged  54,  seen  but  once,  who  had  under- 
gone three  operations,  and  many  x-ray  treatments  which  had 
seemed  to  aggravate  the  trouble,  and  all  resulted  in  an  ulcerated 
mass,  opening  through  the  left  cheek.  In  these  cases  the  dis- 
ease affected  the  left  inner  cheek  four  times,  the  right  cheek 
four  times,  the  front  sub-lingual  region  three  times.  One  man, 
aged  69,  seen  but  once,  had  the  trouble  25  years,  and  had  under- 
gone five  surgical  excisions.  There  was  an  ulceration  1  to  2 
inches  wide  in  the  right  side  of  the  mouth,  with  adenopathy  in 
the  neck.  When  seen  quite  early  lesions  inside  the  mouth  often 
do  very  well,  as  in  the  following  case. 

Case.  LVIII. — Cancer  of  buccal  cavity. — Mr.  N.  F.  E.  aged 
53,  first  seen  May  12,  19 19,  with  a  lesion  on  the  inside  of  the 
right  cheek,  which  was  to  have  been  operated  on  surgically  the 
second  day  following.  He  had  had  white  patches  in  the  mouth 
for  25  to  30  years,  but  experienced  no  annoyance,  until  5  or  6 
weeks  before  his  visit  when  one  of  them  became  sore,  and  it  had 
recently  been  treated  with  nitrate  of  silver.  He  was  in  good 
health,  well  nourished,  and  the  functions  well  performed. 

When  first  seen  there  was  a  slightly  raised,  moderately  hard 
mass,  a  little  granular,  with  a  fissure  in  it.  There  was  no  gland- 
ular enlargement.  No  apparent  cause  for  the  trouble  was  found, 
in  the  way  of  bad  or  rough  teeth.  Under  dietetic  and  medical 
treatment,  with  a  soda  mouth  wash,  used  quarter  of  an  hour 
before  and  after  each  meal,  by  June  4,  it  was  recorded  that  the 
lesion  had  materially  improved,  there  was  no  raw  surface,  and 
very  little  hardness  left;  the  leucopathia  was  lessening.  By 
Aug.  21  he  reported  "everything  all  right,"  no  soreness  on 
eating,  as  before,  and  on  Oct.  23,  he  remarked  "would  not  know 


400  CANCKK 

it  was  there."  Some  little  hardness  remained  on  May  19,  and  as 
he  was  somewhat  restless  under  continued  treatment  I  sent  him 
to  a  good  radium  man,  hoping  that  would  remove  the  slight 
remaining  hardness.  Unfortunately  he  went  to  another  well 
known  radiologist,  and  on  Oct.  12,  1920,  he  wrote  to  me,  in 
answer  to  my  inquiry  "It  was  sad  for  me,  as  the  disease  became 
more  deep  seated,  glands  affected,  etc.  Now  after  months  of 
treatment  I  am  suffering  more  than  ever,  and  while  hope  is 
not  quite  dead,  it  is  nearly  so."  With  the  good  progress  he  had 
previously  made  one  could  not  but  hope  and  expect  that  a 
faithful  continuance  of  the  same,  which  I  fear  he  neglected  in  a 
distant  city,  would  have  completely  overcome  his  disease. 

The  case  of  carcinoma  of  the  soft  palate  in  a  man  aged  47, 
seen  but  once,  presented  no  special  interest.  He  had  had  a  sur- 
gical operation  6  months  before,  with  recurrence,  for  which  he 
had  two  radium  treatments,  which  did  not  relieve  his  great  pain. 
When  seen  the  left  side  of  the  soft  palate  was  the  seat  of  a  grey 
sloughing  mass  of  hard  tissue,  with  swelling  of  the  cheek,  and 
he  could  hardly  open  the  jaws  half  an  inch. 

The  case  of  cancer  of  the  right  tonsil  has  been  already  reported 
Case  XXXIV,  with  very  satisfactory  results,  although  after 
21  months  of  perfect  comfort,  under  fairly  faithful  treatment, 
he  was  failing,  at  the  age  of  75;  this  was  from  involvement 
of  the  deeper  lymphatic  glands,  due  possibly  to  some  oper- 
ative treatment  he  had  had  a  month  before  his  first  visit.  The 
case  of  cancer  of  the  larynx,  in  a  man  aged  48,  was  of  the  usual 
type.  He  had  had  laryngotomy  performed  by  one  of  our  best 
surgeons  in  New  York,  10  months  before  his  visit,  when  he 
seemed  well  for  3  months,  but  there  was  then  recurrence,  for 
which  he  had  been  having  three  radium  treatments  by  Dr. 
Janeway. 

CANCER  OF  THE  HEAD  AND  NECK 

In  this  group  also  are  seen  many  of  the  sad  cases,  generally 
the  result  of  previous  bad  treatment.  Many  of  these  cases 
were  taken  from  the  general  group  of  epithelioma,  as  in  earlier 


CLINICAL  CONSIDERATIONS  AND  RESULTS  401 

years  they  were  first  entered  as  such.  But  careful  study  of  the 
case  papers  and  of  their  later  history  shows  that  they  should 
properly  be  regarded  as  epidermoid-carcinoma  of  the  skin, 
together  with  Paget's  disease,  etc.  The  hundreds  of  cases  of 
early  and  relatively  benign  epitheiiom,  largely  cured  by  #-rays, 
thorium,  etc.,  were  left  under  that  designation,  but  in  these 
cases  the  rebelliousness  and  often  frightful  destruction  of  tissue 
showed  that  the  carcinomatous  habit  or  diathesis  was  actually 
present.  There  were  55  cases  in  this  class,  14  females  and  41 
males.  The  ages  ranged  from  36  to  83  (three  cases  under  40) 
and  the  large  majority  were  in  elderly  persons. 
CANCER  OF  THE  NOSE 

Here  were  placed  16  cases,  eight  females  and  eight  males. 
The  ages  run  from  36  to  78  years,  mostly  in  elderly  people,  for 
omitting  this  young  patient  the  average  age  was  65  years. 
Some  of  the  patients  had  had  the  trouble  for  many  years,  up 
to  20,  and  there  had  been  great  destruction  of  tissue,  under 
varied  treatment.  There  were  two  known  deaths,  one  from 
"cardiac  asthma,"  and  one,  a  lady  of  62  who  had  had  the 
disease  15  years,  with  two  excisions,  and  much  voilet  rays,  but 
who  was  practically  cured  by  thorium  and  x-rays,  which  some- 
times irritated;  she  died  at  67  of  general  debility,  not  from 
cancer. 

Case  LIX. — Epidermoid  carcinoma  of  the  nose.  K.  J.  H., 
aged  36,  Aug.  26,  191 1,  had  had  a  lesion  on  the  left  side  of  the 
nose  for  4  years,  which  had  slowly  increased  in  size  to  the  time 
of  his  visit.  He  had  had  no  special  treatment,  except  cauteriza- 
tion with  nitrate  of  silver,  until  2  months  previously,  when  he 
had  radium  applied  by  a  well  known  expert,  without  apparent 
effect.  He  had  four  applications  of  thorium  paste,  and  when 
seen  May  1,  191 2  there  was  no  trace  of  the  disease,  only  a 
slightly  depressed  normal  scar.  Two  years  and  four  months 
later  he  returned  with  the  recurrence  of  a  small  superficial 
lesion  in  the  scar,  which  was  treated  with  four  applications  of 
thorium  paste,  and  when  last  seen  Feb.  27.  19 15,  there  was  a 
perfect  scar,  but  little  depressed.     Should  there  possibly  be  any 

26 


402  CANCER 

slight  recurrence,  this  would  yield  quite  as  readily  to  the  paste, 
as  it  has  in  other  cases. 

In  the  light  of  experience  of  many  other  serious  cases,  which 
began  just  like  this,  and  that  had  been  cauterized  with  nitrate 
of  silver,  and  when  we  consider  the  deformity  which  might 
result  from  surgery,  especially  with  a  recurrence,  the  result 
was  eminently  satisfactory.  In  contrast  to  this  may  be  men- 
tioned the  following  case: 

Case  LX. — ATose  destroyed  by  epidermoid-carcinoma  and 
treatment.  Mr.  H.  B.  D.  E.,  aged  75,  from  Yucatan,  had  had  a 
hard  lesion  in  the  nose  for  24  years,  not  ^  an  inch  in  diameter, 
which  was  checked  slightly  by  cauterization,  and  gave  no  trou- 
ble until  1900.  Then  a  paste  was  used  for  40  hrs.  and  the 
entire  soft  parts  of  the  end  of  the  nose  sloughed  off,  leaving  an 
ulcerated  area,  which  received  #-ray  treatment  by  a  well  known 
dermatologist,  in  1906  and  again  in  1909  by  another  physician. 
When  seen  the  entire  lower  part  of  the  nose  was  gone,  leaving  a 
characteristic  epitheliomatous  mass  above.  Of  course  little 
could  be  done  for  such  a  case,  and  I  was  not  able  to  follow  it  up. 

Case  LXI. — Epidermoid-carcinoma  of  the  nose.  Miss  E.  G. 
W.,  aged  50,  seen  June  21,  1910,  for  2  or  3  years  had  had 
epitheliomatous  development  on  the  left  side  of  the  nose, 
slowly  increasing  in  size,  which  had  been  treated  only  with 
ointments,  and  apparently  held  in  check.  When  seen  there  was 
a  dusky  red,  epitheliomatous  mass,  about  the  middle  of  the 
left  side  of  the  nose.  With  complete  internal  treatment  and 
seven  mild  a*-ray  exposures  it  was  recorded  on  Aug.  19  that 
everything  had  disappeared,  which  remained  so  when  last  seen 
Apr.  27,  191 1,  and  almost  6  years  later  I  learned  from  her 
physician  that  the  cure  was  perfect. 

CANCER  OF  THE  EAR 

Eight  cases  are  here  recorded,  all  in  males,  four  on  the  left 
ear  and  four  on  the  right,  most  of  them  on  the  upper  edge  of  the 
concha.  The  ages  were  from  34  to  83 ;  leaving  out  the  youngest 
the  average  age  was  68;  four  of  them  were  seen  but  once.     Most 


CLINICAL  CONSIDERATIONS  AND  RESULTS  403 

of  the  patients  had  had  the  disease  several  years,  and  in  several 
the  destruction  was  very  considerable.  One  patient,  aged  66, 
whose  trouble  had  started  on  the  ridge  of  the  left  ear  about  2 
years  previously,  which  he  had  picked,  had  had  #-ray  without 
effect.  He  was  treated  4  months  with  thorium  paste,  in 
various  strengths,  with  benefit,  but  becoming  restless  he  was 
sent  to  Dr.  Kelly,  in  Baltimore,  for  radium  treatment.  After 
about  4^  months  treatment  Dr.  Kelly  wrote  me  that  the 
disease  had  been  very  rebellious  to  treatment,  there  being  great 
destruction,  and  he  was  still  very  doubtful  about  the  outcome. 
When  in  New  York,  from  a  distant  city,  he  had  been  very 
faithful  to  dietetic  and  medical  treatment,  but  I  fear  that  the 
neglect  of  this  may  account  in  part  for  the  poor  results  from 
radium. 

Case  LXII. — Epidermoid-carcinoma  of  the  ear.  Mr.  A.  W.  E. 
aged  69,  came  to  the  office  Oct.  19,  191 7,  with  a  characteristic 
ulcerated  epithelial  mass,  an  inch  long  and  half  an  inch  wide,  on 
the  top  of  the  pinna  of  the  left  ear,  which  had  lasted  3  or  4 
months  and  had  been  picked,  and  bled  as  the  crust  came  off 
repeatedly.  He  had  had  no  treatment.  Under  six  applications 
of  the  thorium  paste  the  ear  became  entirely  well  within  2  months 
leaving  practically  no  scar,  and  on  Feb.  20  he  wrote  that  it  seemed 
as  good  as  ever.  A  similar  case,  in  an  elderly  man,  was  seen  at 
the  New  York  Skin  and  Cancer  Hospital,  treated  with  thorium 
paste,  with  the  same  result.  When  first  seen  there  was  a  large 
area,  over  an  inch  long  by  half  an  inch  wide,  raw  and  oozing, 
with  characteristic  edges.  He  was  shown  repeatedly  in  after 
years  at  my  clinic,  with  a  perfectly  smooth,  slightly  cicatricial 
surface,  and  with  no  recurrence. 

CANCER  OF  THE  FACE 

There  were  23  cases,  five  females  and  18  males,  seen  with 
lesions  on  the  face,  forehead,  and  about  the  eye,  of  various 
degrees  of  severity,  7  of  them  being  seen  only  once  or  twice. 
Only  two  clinical  cures  were  recorded,  but  in  many  instances 
great  improvement  was  noted,  and  possibly  a  cure. 


404  CANCER 

Case  LXIII. — Epidermoid  cancer  at  outer  canthus  ot  eye. 
Mrs.  L.  V.  J.  aged  62,  came  on  Mar.  9,  191 7,  with  a  lesion  Yi 
of  an  inch  long,  at  the  outer  canthus  of  the  left  eye,  which  had 
existed  about  a  year.  She  had  had  no  active  treatment, 
only  mild  ointments.  It  was  moderately  raised  and  of  a 
waxy  appearance,  a  characteristic  basal  cell  epithelioma.  She 
was  a  large  woman,  of  flabby  texture,  weighing  221^  lb.,  which 
by  strict  diet  and  medication  was  reduced  to  191  lb.  in  about  5 
months.  Under  nine  applications  of  thorium  paste  the  cancer 
lesion  had  entirely  disappeared,  leaving  only  a  slight  red  stain 
and  no  scar.  Where  this  is  compared  with  the  results  com- 
monly seen  from  surgery  in  this  region  the  result  is  indeed 
satisfactory. 

Case  LXIV. — Epidermoid  cancer  over  right  eye.  Mrs.  S.  W.  J. 
aged  74,  came  on  Oct.  15,  1920,  on  account  of  an  epitheliomat- 
ous  mass  over  the  right  eye  fully  an  inch  in  diameter,  and 
raised  }^  of  an  inch,  resulting  from  a  wound  25  years  previously, 
which  had  never  healed.  This  had  not  given  much  trouble, 
but  in  191 7  a  warty  growth  had  formed  which  had  gradually 
increased  in  size  and  had  bled  when  the  crust  was  knocked  off. 
She  then  underwent  electrical  treatment  for  a  year  with  one 
physician,  and  since  then  high  frequency,  violet  rays,  etc. 
Under  six  applications  of  thorium  paste  it  was  recorded  on 
December  13  that  all  disease  had  entirely  gone  leaving  a  very 
good  scar,  and  when  seen  later  this  had  so  improved  under  a 
calamine  and  zinc  ointment  that  it  was  hardly  noticeable. 

A  word  of  caution  has  already  been  given  in  the  section  on 
epithelioma,  in  regard  to  the  employment  of  the  thorium  paste, 
for  in  inexperienced  hands  I  have  seen  very  serious  damage 
done,  as  in  a  patient  at  my  hospital  clinic  where  some  outside 
physician  had  used  it  with  the  result  of  destroying  the  left  side  of 
the  nose  almost  completely,  leaving  a  great  permanent  opening. 

CANCER  OF  THE  NECK 

Nine  cases,  all  males,  are  placed  here,  in  which  the  disease 
appeared  primarily  on  the  neck:  the  ages  ranged  from  30  to 


CLINICAL  CONSIDERATIONS  AND  RESULTS  40.S 

75  years,  with  an  average  of  54  years.  Some  of  them  were 
post-operative,  one  patient  having  had  five  operations,  others 
#-rays,  and  all  were  rebellious  to  treatment,  but  none  of  them 
present  special  interest  to  report.  These  eight  cases  on  the 
neck  are  in  addition  to  the  many  others  seen  where  there  were 
secondary  lesions  in  the  neck  from  metastatic  involvement, 
generally  from  mouth  lesions.  These  latter  are  often  most 
distressing  and  quite  inoperable;  also  they  are  generally  seen 
too  late  for  medical  treatment  to  have  any  great  curative  effect, 
although  much  benefit  has  often  been  obtained  by  exactly  the 
right  internal  and  local  measures. 

CANCER  OF  THE  (ESOPHAGUS,  STOMACH,  LIVER,  AND  INTESTINES 

With  the  often  distressing  forms  of  cancer  seen  in  these 
localities,  there  were  51  patients,  17  females  and  34  males. 
Unfortunately  a  large  number  of  them  were  seen  only  once  or 
twice,  or  in  consultation,  and  naturally  there  were  very  few 
clinical  cures,  although  improvement  or  great  improvement  was 
recorded  in  many  cases,  in  regard  to  comfort,  relief  from  pain 
without  opiates,  and  lengthening  of  life.  There  were  only  six 
known  deaths,  but  there  must  have  been  very  many  more,  as 
a  number  of  the  patients  were  in  a  desperate  condition  when 
seen,  with  advanced  cancer  pronounced  incurable  by  some  of  the 
best  surgeons.  As  the  prospects  of  medical  relief  become  more 
widely  known  and  accepted,  and  earlier  diagnosis  is  made,  more 
lives  will  be  saved.  The  ages  of  the  patients  varied  somewhat, 
according  to  the  location  of  the  disease,  as  will  be  seen  later, 
but  the  large  majority  were  well  advanced  in  life. 

CANCER  OF  THE  (ESOPHAGUS 

Six  cases  are  found  here,  two  females  and  four  males:  their 
ages  ranged  from  51  to  65,  with  an  average  of  almost  60  years. 
In  one  of  them  the  upper  portion  of  the  oesophagus  and  larynx 
were  affected,  and  one  at  the  cardiac  portion.  One  of  them,  a 
female,  had  had  gastrostomy  performed. 


406  CANCER 

Case  LXV. — Cancer  of  the  oesophagus.  Mrs.  M.  B.  aged  64, 
seen  Sept.  15,  1920,  had  already  had  a  gastrostomy  performed, 
and  for  5  months  had  been  fed  through  the  opening,  maintain- 
ing a  quite  fair  condition,  though  she  had  lost  flesh,  from  160 
to  105  lb.  When  seen  they  were,  however,  feeding  her  with 
animal  broth,  eggs,  and  milk,  which  only  favored  the  develop- 
ment of  the  cancerous  state.  This  line  of  feeding  was  of  course 
stopped  and  all  nutriment  was  made  to  come  from  the  vegetable 
kingdom.  She  was  also  receiving  codeine,  because  of  a  certain 
amount  of  digestive  pain,  this  was  also  stopped  and  further 
remedies  substituted.  This  is  a  very  recent  case  and  no  judg- 
ment can  be  formed  from  it.     One  other  case  is  interesting. 

Case  LXVI. — Cancer  of  the  oesophagus.  Mr.  G.  M.  aged  55, 
first  came  under  my  care  July  31,  19 19.  Eight  months  previ- 
ously he  began  to  notice  difficulty  in  swallowing,  which  had 
gradually  increased.  He  had  been  examined  by  a  good  stomach 
specialist,  diagnosing  oesophageal  cancer,  and  10  weeks  previ- 
ously he  had  had  a  careful  study  by  a  hospital  physician.  The 
bougie  met  two  obstructions,  deep  in  the  oesophagus,  and  the 
#-ray  showed  a  shadow,  i}i  by  3  in.  He  had  lost  15  lb.  and 
weighed  in,  was  cachectic,  pulse  100,  tongue  coated,  and  saliva 
acid,  and  had  long  been  constipated. 

On  September  4,  being  under  full  dietetic  and  medical  treat- 
ment it  was  recorded  that  he  felt  very  well,  "very  little  difficulty 
in  swallowing,  now  eats  finely — was  a  torture  before."  On 
December  8,  his  weight  was  113^  lb.,  but  some  evidences  of 
metastasis  were  occurring,  with  some  dullness  in  the  epigastric 
region  and  moderate  pain  on  manipulation.  Shortly  some 
manifestations  of  kidney  involvement  appeared,  with  swollen 
ankles,  but  during  this  entire  time  to  February  2,  for  6  months 
from  first,  he  had  attended  to  his  duties  as  sexton  of  a  Jewish 
Synagogue,  and  was  able  to  come  repeatedly  to  my  office  from 
another  city,  and  was  reasonably  comfortable,  with  little 
difficulty  in  swallowing. 

On  Feb.  21,  1920,  I  was  called  to  another  city  to  see  him  in 
consultation  with  his  physician,  as  the  day  before  he  had  felt 


CLINICAL  CONSIDERATIONS  AND  RESULTS  407 

badly  and  vomited  blood  at  4  o'clock  that  morning,  at  first 
red,  then  black,  and  it  looked  as  though  he  would  succumb  very- 
soon.  He  was  in  bed,  and  a  sorry  figure;  we  could  find  no 
special  cause  for  the  occurrence.  There  was  now  pain  on 
percussion  over  the  epigastric  region,  and  apparently  some 
solid  mass  there,  and  considerable  dullness  in  the  left  iliac 
region,  with  abdominal  cramps,  although  the  bowels  had 
been  acting  freely  all  the  time,  with  the  mixture  he  had  been 
taking.  Under  extra  digestive  remedies,  and  minute  and  often 
repeated  doses  of  the  tincture  of  colocynth,  he  improved  at 
once,  so  that  on  March  17,  his  doctor  wrote  me  that  "he  had 
improved  greatly,  walks  about  the  house,  and  had  even  been 
to  the  Synagogue."  He  added  that  he  was  "amazed  at  the 
result  of  treatment,  it  is  mysterious,  if  not  miraculous."  He 
was  able  to  come  and  see  me  several  times  after  this,  but  the 
liver  became  gradually  affected,  and  on  June  10,  liver  dullness 
extended  about  2  in.  below  the  ribs,  with  some  pain  on  percussion 
over  the  epigastric  region. 

As  I  have  not  seen  him  since  I  presume  that  he  gradually 
succumbed  to  his  disease,  showing  that  while  very  much  can 
be  done  medically  for  these  patients,  greater  advances  will 
have  to  be  made  before  we  can  expect  to  cure  them  all.  The 
patient,  however,  has  had  nearly  a  year  of  relative  comfort  and 
activity,  with  absolutely  no  opiate,  and  stands  in  striking 
contrast  to  the  case  just  before  briefly  noticed.  In  her  case 
the  gastric  tube  feeding  cannot  long  sustain  life,  besides  the 
seriousness  of  the  operation  and  the  constant  annoyance  of 
the  leaky  gastric  fistula,  only  a  little  less  distressing  than  a 
colostomy,  are  to  be  taken  into  consideration. 

CANCER  OF  THE  STOMACH 

There  were  28  cases  recorded,  four  females  and  twenty-four 
males;  in  a  number  of  them  marked  involvement  of  the  liver 
was  noted.  Only  two  patients,  males,  aged  31  and  36,  were 
under  40  years  of  age,  the  oldest  was  75  and  the  average  a  trifle 
under  60.     There  were  three  between  40  and  50,  11  between 


4o8  CANCER 

50  and  60,  nine  between  60  and  70,  and  three  70  years  or  over. 
In  12  of  the  cases  the  disease  had  been  recognized  more  or  less 
definitely  from  2  to  7  months,  in  many  of  them  from  1  to  2  years. 
Two  had  had  recent  gastroenterostomy,  and  several  had  had 
exploratory  operations  revealing  inoperable  cancer  of  the 
stomach;  the  .v-ray  and  other  diagnostic  measures  had  been 
employed  in  many  cases,  and  all  the  patients,  I  think,  had  had 
the  diagnosis  confirmed  by  several  physicians  and  surgeons. 
X-ray  had  been  employed  therapeutically  in  some  cases  but  I 
find  no  mention  of  radium.  Only  five  of  the  patients  are  known 
to  have  died,  but  there  were  many  seen  only  once  or  twice,  or 
in  consultation,  who  must  have  succumbed  soon.  One  of  the 
patients  a  man  aged  56  has  been  already  reported,  Case  XXVIII 
as  clinically  cured,  so  as  to  return  to  and  continue  at  his  work. 

Case  LXVII. — Inoperable  cancer  of  the  stomach.  Mr. 
D.  F.  B.  aged  68,  was  referred  to  me  June  15,  1919,  with  the 
history  of  stomach  distress  and  a  tumor  in  the  right  upper 
abdomen,  dating  back  5  months,  with  weakness  and  loss  of  10 
pounds  in  weight,  and  he  was  pale  and  cachectic,  with  great 
constipation.  A  firm,  nodular  mass  was  found  in  the  upper 
abdominal  cavity,  not  freely  movable,  about  2  inches  in 
diameter.  Being  placed  on  full  dietary  and  other  treatment  he 
returned  to  his  physician,  in  a  distant  city,  and  the  nurse  wrote 
me  on  August  5,  that  he  seemed  better,  the  last  3  weeks,  walking 
further,  half  a  mile  without  fatigue.  Seeing  him  the  same  day 
his  weight  was  111^  lb.,  and  he  appeared  much  better,  with 
some  soreness  after  the  noon  meal.     The  saliva  was  very  acid. 

On  August  27,  he  weighed  115M  lb.,  seemed  very  much 
brighter  and  better,  and  it  was  recorded  that  the  mass  in  the 
gastric  region  seemed  far  less  than  at  the  first  visit,  though 
some  indefinite  nodular  masses  were  found  below  the  ribs,  on 
both  sides.     The  saliva  was  still  very  acid. 

On  September  18,  the  weight  was  117  lb.,  and  he  stated  that 
he  "felt  very  well,  the  same  as  a  year  ago,"  saliva  less  acid. 
Examination  showed  the  gastric  mass  still  firm,  but  less  in 
size.     The  bowels  were  acting  finely,  twice  daily.     On  Sep- 


CLINICAL  CONSUMMATIONS  AND   RESULTS  409 

tember  25,  he  insisted  that  the  mass  in  the  gastric  region  was 
all  gone,  but  it  could  be  felt,  now  somewhat  movable.  He 
then  went  to  his  home  in  Florida,  in  a  very  different  condition 
from  that  at  first.  He  had  been  perfectly  comfortable  for  over 
3  months,  and  his  gain  in  weight  was  interesting.  When  he 
left  New  York  he  seemed  bright  and  normal,  and  wrote  repeat- 
edly of  his  condition.  But  probably  he  relaxed  in  some  way 
as  to  his  diet  and  treatment,  and  metastasis  undoubtedly 
occurred.  The  ordinary  drinking  water  there  seemed  to  disturb 
him,  and  his  kidneys  acted  badly,  cedema  of  the  feet  came  on, 
with  also  ascites,  for  which  he  was  tapped.  The  urine  came 
down  to  half  a  pint  or  a  pint  daily,  and  he  gradually  became 
worse,  until  on  December  18,  he  wrote  "I  won't  be  here  long," 
and  I  presume  he  passed  away.  While  the  ultimate  result  was 
only  what  might  be  expected,  the  early  results  of  treatment  were 
certainly  encouraging,  and  possibly  would  have  been  better  if 
he  could  have  remained  here  under  careful  supervision. 

Case  LXVIII. — Cancer  of  the  stomach.  Dr.  W.  L.  T.  aged  70, 
first  seen  on  May  5,  1920,  had  had  digestive  trouble  for  15 
months,  with  loss  of  weight  the  past  4  months;  his  weight  was 
159^  pounds,  the  weight  for  his  height,  6  ft.  2  in.,  and  age, 
should  be  190  pounds.  In  April  he  had  had  15  deep  x-ray  treat- 
ments over  the  stomach.  His  bowels  had  been  always  consti- 
pated, depending  upon  an  enema  for  20  years,  and  the  saliva 
was  very  acid ;  his  sleep  was  very  bad,  lying  awake  for  hours 
after  2   a.m. 

He  brought  a  long  and  most  elaborate  and  scientific  fluoro- 
scopic and  other  study  of  his  internal  condition,  by  an  excellent 
observer,  which  need  not  be  all  entered  here.  These  showed 
"carcinoma  of  the  stomach,  involving  the  greater  curvature 
at  pars  media,  with  beginning  stasis  in  the  stomach."  There 
was  free  hydrochloric  acid,  with  a  total  acidity  of  18,  a  trace  of 
lactic  acid,  also  Oppler-Boas  bacilli,  some  pus  cells  and  a  few 
red  blood  cells.  Wasserman  negative.  The  haemoglobin  stood 
at  57  (Dare),  erythrocytes  3.160.000,  leucocytes  6.900,  poly- 
morph. 82.2  per  cent,  small  lymphocytes  10.3  large  lymphocytes 
3.8,  transitional  2.2,  and  large  mono-nuclear  1.5  per  cent. 


410  CANCER 

He  was  under  observation  and  treatment  for  only  6  weeks, 
when  he  left  for  the  West,  but  the  change  in  his  condition  during 
that  time  was  most  gratifying  to  himself  and  to  me.  At  the 
fifth  visit  he  expressed  himself  as  feeling  very  different,  and  had 
still  gained  a  little  in  weight.  He  was  lively  and  bright,  with 
improved  color,  bowels  acting  well,  sleep  much  better,  and 
saliva  neutral.  As  a  doctor  he  thought  he  was  overcoming  his 
trouble. 

There  is  relatively  little  of  importance  to  note  regarding  the 
other  cases  of  stomach  cancer,  all  giving  the  same  story,  having 
seen  many  physicians  and  surgeons,  with  s-ray  diagnosis  of 
cancer  etc.  Four  had  been  operated  upon;  and  two  had  had 
exploratory  operations.  While  relatively  few  were  observed 
long  enough  to  speak  definitely  of  permanent  results,  it  is 
interesting  in  studying  the  case  records  to  note  how  continu- 
ally there  was  a  decided  change  for  the  better  after  beginning 
treatment.  But  with  the  general  feeling  of  hopelessness  in 
regard  to  cancer,  and  the  commonly  expressed  opinion  by 
surgeons  and  others  that  if  an  operation  is  not  possible  there  is 
nothing  else  that  can  be  done,  it  is  often  difficult  to  persuade 
patients  to  be  faithful  to  the  necessarily  tedious  process  of 
dietetic  and  medicinal  treatment;  so  in  a  number  of  instances 
they  shortly  dropped  off,  when  feeling  better. 

Case  LXIX. — Inoperable  cancer  of  the  stomach,  omentum 
etc.  Dr.  K.I.  M.  aged  52,  seen  Oct.  21,  1920.  He  had  had  vague 
stomach  symptoms  for  many  years,  but  active  syndromata,  pain 
and  distension,  for  ij^  years,  for  which  he  had  had  gastric 
lavage,  etc.  In  January  and  July  the  #-ray  reveated  carci- 
noma at  the  pylorus,  and  he  had  lost  80  lb.  since  January  1. 
On  August  6  he  had  an  exploratory  operation  by  Dr.  Wm.  J. 
Mayo,  who  found  "  colloid  cancer  of  the  pylorus  with  metastases 
to  the  greater  omentum  and  transverse  mesocolon,"  absolutely 
inoperable,  and  he  remarked  to  his  medical  son  "the  future  of 
cancer  of  the  stomach  is  medical."  Ascites  developed  10  to  14 
days  after  the  operation,  for  which  he  had  been  tapped  several 
times.     He  had  been  chronically  constipated,  depending  always 


CLINICAL  CONSIDERATIONS  AND  RESULTS  411 

on  an  enema.  Of  course  medical  treatment  could  have  no 
possible  chance,  in  such  a  condition  of  advanced  carcinosis,  and 
the  patient  died  early  in  December. 

Case  LXX. — Post-operative  cancer  of  the  stomach.  Mr. 
S.  A.  W.  first  seen  July  27,  1920.  For  4  years  he  had  had  great 
gastric  symptoms,  much  higher  acidity  as  shown  by  many 
gastric  analyses,  also  vomiting,  so  that  he  could  not  even 
retain  test  food.  He  had  been  in  the  Navy  for  24  years,  and 
during  the  war  had  made  many  trips  with  troops,  though  a 
sick  man.  In  February  19 19  he  had  had  various  tests  by  Dr. 
Charles  Mayo,  with  the  diagnosis  of  an  operable  cancer,  and  he 
operated  on  him,  removing  a  small  growth,  probably  external  to 
the  stomach,  which  was  pronounced  cancerous,  microscopically, 
and  he  was  given  3  to  6  months  to  live.  He  felt  better  after 
the  operation  and  returned  to  army  transportation,  in  3  months. 
But  the  vomiting  began  again,  with  intense  cramps,  and  about 
November  8  he  was  very  weak,  weight  104  pounds  which  had 
been  165.  He  then  went  to  the  Walter  Reed  Hospital,  and  the 
day  after  Thanksgiving  a  gastroenterostomy  was  performed  for 
cancer  of  the  pylorus,  after  which  he  gained  up  to  150  pounds, 
2  months  before  his  visit;  this,  however,  had  again  run  down 
to  139^  at  his  visit. 

When  seen  he  was  in  a  pretty  bad  condition,  tongue  coated 
and  bowels  very  constipated,  depending  entirely  on  enemata, 
and  his  sleep  was  very  bad,  often  not  for  more  than  an  hour  or 
two  on  account  of  gastric  pain.  Being  placed  on  full  dietetic 
and  medicinal  treatment,  in  1  month  it  was  recorded  that  he 
"feels  ever  so  much  better  in  every  way,  draggy  pains  gone" 
The  lump  over  the  pylorus  was,  of  course,  still  present  and  even 
visible,  2  to  3  in.  in  diameter,  but  not  very  hard.  Much  of  the 
time  there  was  no  pain  and  he  had  good  sleep  from  lying  down 
till  morning,  with  about  5  gr.  of  potassium  bromide  and  chloral 
in  elixir  of  lactopeptine;  the  bowels  were  acting  freely  with  the 
mixture  given  to  so  many  others.  Two  weeks  later  no  dullness 
or  tumor  could  be  discovered  at  the  pylorus,  it  seemed  to  have 
moved  to  the  left.     But  there  was  a  mass  of  mesenteric  glands 


4I2  CANCER 

felt,  which  were  a  little  painful  at  times,  when  standing  erect. 
From  his  general  appearance  and  feelings  it  did  seem  as  though 
with  very  careful  and  prolonged  treatment  the  disease  might 
be  overcome. 

But  his  duties  at  the  Navy  Yard,  and  various  matters 
prevented  him  from  carrying  out  everything  faithfully.  He 
developed  a  grippy  bronchitis,  and  then  was  called  to  Washing- 
ton on  September  19,  and  the  next  I  heard  of  him  was  in  a 
letter  from  his  wife  on  October  22  saying  that  he  had  died  on 
September  30,  as  a  result  of  the  operation  performed  on  him 
on  the  28th.  He  lived,  however,  1  year  and  7  months  after  he 
had  been  given  but  3  to  6  months  to  live,  in  February,  19 19, 
and  while  he  was  under  full  treatment  he  was  more  comfortable 
than  for  a  long  time,  with  no  nausea  or  vomiting,  and  practically 
no  pain  after  he  had  gotten  well  under  treatment.  How 
much  longer  he  would  have  lived  but  for  the  operation  no  one 
knows. 

A  recent  case,  observed  for  10  months,  shows  how  much  can 
be  accomplished  under  the  most  absolute  and  perfect  carrying 
out  of  every  detail  of  treatment. 

Case  LXXI. — Primary  cancer  of  the  stomach.  Mr.  V.  H.  aged 
75  came  under  treatment  May  8,  1920.  his  very  intelligent 
daughter  coming  with  him  always  and  supervising  the  carrying 
out  of  every  order  given.  In  September,  191 1,  he  had  some 
operation  at  one  of  the  New  York  Hospitals,  but  on  careful 
inquiry  no  record  could  be  found  as  to  its  nature;  there  was  a 
large  scar  of  an  incision  which  had  been  made  in  the  region  of 
the  stomach.  For  the  next  7  years  he  always  had  abdominal 
discomfort,  with  a  sense  of  fullness,  though  keeping  at  work,  as 
a  time  keeper.  He  had  had  pain  beneath  the  scars  for  a  year. 
About  1  month  before  his  visit  he  had  vomiting,  and  pain  in 
the  upper  abdomen,  for  which  he  applied  a  hot  water  bottle 
which  may  have  caused  the  ulcerated  area  2  or  3  in.  in  diameter 
over  the  scar,  which  was  really  the  cause  of  his  visit.  He  had 
always  been  much  constipated,  with  poor  digestion. 

When  first  seen  there  could  be  felt  quite  a  mass  beneath  the 


CLINICAL  CONSIDERATIONS  AND  RESULTS  413 

ulceration,  which  latter  healed  completely  in  a  month  or  so, 
under  the  constant  application  of  a  soothing  ointment.  The 
epigastric  mass  could  then  be  readily  discovered  by  percussion 
and  palpatation,  under  which  it  was  a  little  tender.  Within  2 
months  from  the  first  he  declared  that  he  had  no  trouble  with 
the  stomach,  no  pain  or  vomiting,  and  does  not  yet  know  of  the 
serious  nature  of  his  disease,  though  his  daughter  is  fully 
acquainted  with  it,  and  keeps  him  faithful  in  diet  and  medi- 
cation, and  he  keeps  steadily  at  his  work,  walking  some  miles 
every  day  to  it.  He  has  gained  somewhat  in  weight  during 
these  10  months,  though  he  has  had  one  or  two  set  backs  from 
severe  lumbago,  which  has  yielded  to  treatment.  When  last 
seen  Mar.  3,  1921,  he  appeared  as  healthy  and  robust  as  could 
be  desired,  but  there  was  still  dullness  in  the  epigastric  region 
and  a  little  pain  on  deep  pressure,  but  absolutely  no  stomach 
symptoms. 

CANCER  OF  THE  LIVER 

In  quite  a  number  of  cases  of  cancer  in  various  localities 
there  were  very  distinct  indications  of  metatastic  involvement 
of  the  liver,  both  by  clinical  symptoms  and  physical  exami- 
nation, and  also  by  jaundice  and  ascites,  as  well  as  by  explor- 
atory operations.  In  addition  to  these  there  were  four  cases  in 
which  the  liver  was  so  prominently  affected,  with  no  other 
lesion  of  cancer  elsewhere  at  the  time,  that  one  or  two  of 
them  at  least,  were  regarded  as  primary  carcinoma  of  the 
liver,  although  this  is  known  to  be  quite  rare.  A  case  or  two 
illustrating    the    former    condition   may  be    first    mentioned. 

Case  LXXII. — Cancer  of  the  stomach  and  liver.  Mr.  G.  S. 
aged  59,  first  seen  Aug.  11,  1920,  had  had  stomach  trouble 
for  5  or  6  months,  heaviness,  pain,  vomiting,  for  which  he  soon 
went  to  a  hospital  in  this  city,  for  observation.  He  was  there 
nine  weeks,  under  #-ray  treatment,  but  the  abdomen  soon 
began  to  swell  with  fluid,  and  he  was  tapped.  This  aspiration 
was  repeated  three  times  in  another  hospital,  nearly  a  gallon 
being  drawn  off  on  August  8.     When  seen,   soon  after  the 


414  CANCER 

tapping,  the  abdomen  seemed  very  full  of  metastatic  masses, 
with  a  large  area  of  dullness  over  the  epigastric  region. 
He  was  constipated,  the  urine  scanty  and  milky,  and  the 
saliva  very  acid;  he  weighed  123^  lb.,  having  come  down  from 
150.  Of  course  little  if  anything  could  be  expected  from  diet  or 
medication  in  such  a  case,  and  little  if  any  benefit  resulted 
before  he  ceased  his  visits. 

Case  LXXIII. — Cancer  of  the  liver  secondary  to  uterine  cancer. 
Mrs.  G.  S.  aged  51,  seen  Feb.  8,  1919,  had  had  the  uterus  and 
ovaries  removed  for  carcinoma  in  June  1914,  by  an  eminent 
surgeon,  whose  son  at  the  same  time  operated  also  for  gall 
stones,  draining  the  gall  bladder.  In  August  19 17,  a  mass  had 
appeared  in  the  region  of  the  gall  bladder,  and  in  November 
1917,  another  prominent  surgeon  removed  a  mass  of  adeno- 
carcinoma near  the  liver,  the  size  of  a  hen's  egg.  The  wound 
was  left  open  and  in  December  radium  was  used  on  it  for  8  hr., 
at  the  Memorial  Hospital.  In  March  1918,  a  large  dosage  of 
radium  was  again  used,  and  again  in  July,  all  causing  much 
suffering  and  apparently  causing  the  tumor  to  grow.  In 
September  the  wound  opened  up,  and  Alpine  Sun  light  was 
applied,  under  which  the  tumor  developed  externally,  as  a 
cauliflower  excresence,  2  in.  in  diameter.  On  January  8, 
jaundice  appeared.  Pain  had  never  ceased  since  the  operation 
in  191 7,  and  was  not  controlled  by  narcotics. 

When  seen  there  was  a  granulating  mass  over  the  lower 
margin  of  the  ribs,  3  or  4  in.  in  diameter,  secreting  profusely, 
and  she  was  in  great  pain,  groaning  day  and  night.  She  had 
always  been  extremely  constipated,  latterly  the  movements 
were  very  white,  and  the  urine  very  scanty.  The  mass  was 
dressed  with  a  soothing  calamine  and  zinc  ointment,  spread 
thickly  on  thin  layers  of  absorbent  cotton,  which  gave  great 
relief.  With  the  diet  and  medicine  given  she  seemed  better, 
the  bowels  acting  twice  daily,  and  the  pains  materially  lessened 
by  chloral  and  sodium  bromide,  in  elixir  of  peptenzyme.  But 
the  weakness  continued  and  she  passed  away  peacefully  without 
an  opiate  about  a  month  later. 


CLINICAL  CONSIDERATIONS  AND  RESULTS  415 

Case  LXXIV. — Cancer  of  the  liver  secondary  to  removal  of 
cancer  of  the  small  intestine.  Mrs.  R.  A.  aged  50,  was  well  and 
hearty  until  2  years  ago.  There  was  then  pain  in  the  upper 
abdominal  region  and  a  prominent  surgeon  removed  an  adeno- 
carcinoma from  the  ileum,  on  July  7,  19 18.  A  second  and  then 
a  third  operation  was  performed,  and  she  was  well  for  a  year  or 
so.  Then  there  was  pain  over  the  liver  and  on  August  14,  an 
exploratory  operation  was  performed,  revealing  a  large  mass 
over  the  liver,  with  nodules,  some  which  were  removed  and 
found  microscopically  to  be  adeno-carcinoma.  When  seen  in 
consultation,  10  days  later  on  Aug.  24,  1920,  she  was  in  a  low 
condition  being  fed  on  a  high  protein  diet,  and  although  she 
rallied  and  all  thought  that  she  was  much  better  the  first  week 
or  so,  under  the  measures  advised,  she  succumbed  within  2 
weeks  to  the  great  amount  of  metatastic  encroachment  of  the 
disease.  The  last  operation,  with  partial  removal  of  diseased 
tissue  was  a  great  shock  to  her  system,  and  undoubtedly  has- 
tened the  lethal  end. 

Case  LXXV. — Primary  cancer  of  the  liver.  Mrs  K.  C.  R. 
aged  66,  had  always  been  constipated  and  with  a  "torpid  liver/' 
Six  weeks  before  my  seeing  her,  when  South,  she  had  a  severe 
attack  of  indigestion  after  taking  some  clam  broth,  with  purg- 
ing and  beginning  of  jaundice.  On  the  way  North  the  case  was 
studied  by  physicians  in  Philadelphia  and  Washington  with 
x-ray,  blood  tests  etc.,  as  also  in  New  York,  and  while  no  definite 
diagnosis  was  made  all  pointed  to  be  neoplasm  in  the  region  of 
the  gall  bladder. 

When  I  saw  her,  May  11,  1914,  it  was  really  on  account  of  the 
terrific  itching  caused  by  the  jaundice,  which  nearly  drove  her 
crazy,  and  had  been  severe  from  the  beginning,  the  body  and 
limbs  being  covered  with  scratch  marks.  The  jaundice  was 
as  severe  as  could  be,  everywhere,  the  pulse  was  40  and  irregular, 
64  beats  by  auscultation,  urine  scanty  and  dark  yellow. 

Under  a  rice  diet  and  active  medication,  internal  and  external, 
the  itching  was  soon  very  greatly  controlled,  so  that  on  May  14 
it  was  recorded  that  there  was  very  little  trouble  from  it,  and 


416  CANCER 

she  was  sleeping  perfectly,  and  in  a  few  days  the  stools  which, 
had  been  white  and  acholic,  were  formed  and  of  good  color, 
but  the  urine  was  still  dark,  though  with  much  less  bile. 

A  very  careful  study  of  the  abdominal  region  revealed  the 
left  lobe  of  the  liver  at  the  costal  margin,  and  the  right  lobe 
projecting  down  to  the  level  of  the  umbilicus,  moving  with 
respiration,  irregular  in  shape,  at  one  place  nodular.  Beneath 
the  right  lobe  there  was  a  second,  smaller  mass  in  the  region  of 
the  head  of  the  pancreas.  The  stools  had  been  curdy,  with  no 
bile,  but  under  mercurial  purges  she  had  had  those  of  good  color 
at  times.  Under  treatment  the  urine,  which  had  been  scanty, 
rose  to  6 1  oz.  on  one  day,  and  had  improved  in  many  respects, 
there  being  but  a  trace  of  albumin,  and  amorphous  urates,  but 
hardly  any  bile  when  last  seen.  She  passed  from  under  my 
observation  soon  after  her  skin  symptoms  had  been  relieved. 
There  was  no  history  or  evidence  of  any  other  manifestation  of 
carcinoma  from  which  the  liver  mass  could  be  a  metastasis,  and 
no  particular  evidence  of  gall  stones,  certainly  she  never  passed 
any.  So  this  case  was  regarded  as  probably  a  primary  cancer 
of  the  liver. 

Case  LXXVI. — Possible  primary  cancer  of  the  liver.  A  some- 
what similar  case  was  that  of  Mrs.  B.  I.  aged  58,  seen  Nov.  7, 
19 19  who  was  in  a  very  bad  condition,  with  great  constipation, 
much  jaundice,  very  yellow  urine,  and  a  mass  in  the  right 
hypochondrium,  and  bad  stomach  symptoms,  with  belching  of 
much  gas.  But  some  time  later  I  learned  from  her  physician 
that  under  dietetic  and  other  treatment  she  was  very  much 
better,  sitting  up.  No  other  cancerous  lesion  existed,  and  this 
appeared  also  like  a  primary  cancer  of  the  liver. 

The  case  of  cancer  of  the  mesentery  and  that  of  the  omentum 
presented  no  particular  interest,  and  were  not  followed  long. 
That  in  the  mesentery  was  probably  from  stomach  cancer,  the 
liver  being  also  much  affected,  over-riding  the  stomach,  with 
tenderness.  There  had  been  an  exploratory  operation  in  which 
the  piece  removed  showed  metatastic  carcinoma  microscopic- 
ally. The  patient  with  omental  disease,  a  female,  exhibited  a 
mass  3  to  4  in.  in  diameter  to  the  right  of  the  umbilicus,  and  a 


CLTNICAL  CONSIDERATIONS  AND  RESULTS  417 

smaller  one,  about  2  in.  in  size,  on  the  left  side  probably  from  a 
former  cystic  adenoma  of  the  right  ovary.  The  case  of  carcin- 
oma of  the  sigmoid  was  followed  3  months  and  was  interesting. 

Case  LXXVII. — Cancer  of  sigmoid.  Mr.  C.  H.  W.  aged  54, 
living  in  a  distant  city,  began  to  be  greatly  constipated  2  years 
before  he  was  first  seen  Oct.  11,  1919.  For  this  he  took  much 
salts  and  other  laxatives  and  had  diarrhoea,  with  blood  and 
mucus.  He  saw  several  surgeons  and  a  proctoscopic  examina- 
tion revealed  a  mass,  with  ulcerations  high  up,  for  which  he  was 
given  injections  of  a  gallon,  with  a  teaspoonful  of  salt  to  the 
quart.  With  this  he  improved  and  passed  no  more  blood;  he 
was  on  a  mixed  diet,  with  some  animal  proteins. 

When  seen  he  weighed  154  lb.  having  fallen  from  163,  and 
seemed  in  fair  general  condition,  though  the  saliva  was  very 
acid,  the  urine  acid  and  of  high  specific  gravity,  the  tongue 
white  and  coated,  and  he  had  some  diarrhoea.  Under  careful 
treatment  in  three  weeks  he  said  that  he  felt  "very  well," 
sleeping  finely  and  seemed  in  much  better  condition.  Two 
months  later  evidence  of  liver  involvment  appeared,  with  sharp 
pains  there,  lasting  10  to  15  min.,  several  times  daily,  decided 
jaundice  set  in,  and  dark  yellow  urine.  On  December  1  he  was 
sent  to  a  New  York  surgeon  who  found  a  large  sigmoid  neoplasm 
below  the  true  pelvic  rim.  He  was  lost  sight  of  some  months 
after  first  seen,  but  in  the  mean  time  he  was  very  comfortable, 
with  no  pain  and  no  opiate. 

CANCER  OF  THE  RECTUM 

Eight  cases  of  the  disease  in  this  location  were  observed,  four 
females  and  four  males;  four  of  the  patients  were  seen  only  once, 
or  in  consultation.  The  ages  ran  from  26  to  55  years,  with  an 
average  of  40  years.  Three  of  them  had  had  colostomy,  one  of 
them  two  operations,  and  one  had  had  three.  One  of  the  four 
treated  died,  as  expected,  and  of  the  others  one  is  recorded  as 
improved  and  two  as  greatly  improved.  One  case  has  been 
already  reported,  Case  XXIX,  another,  of  rather  recent  date, 

although  ultimately  fatal,  presents  great  interest. 

27 


418  CANCER 

Case  LXXVI. — Cancer  of  the  rectum.  Mr.  H.  A.  G.  aged  41 
came  to  me  on  Feb.  18,  1920.  He  had  always  been  constipated, 
taking  medicine,  and  for  7  years  had  had  bleeding  piles.  One 
year  prior  to  his  visit  one  pile,  on  the  left  side,  had  been  re- 
moved under  local  anaesthesia.  Three  weeks  before  his  visit 
his  family  physician  had  examined  him,  and  found  an  extensive 
growth  just  above  and  about  the  anus.  He  weighed  143  lb, 
having  fallen  from  155,  was  fairly  nourished,  but  of  a  sallow, 
cachectic  hue,  tongue  white  and  coated,  saliva  very  acid,  very 
constipated,  and  with  movements  the  size  of  a  pencil.  Exami- 
nation showed  a  hard  mass,  around  and  within  the  anus,  with 
some  external  piles,  easily  bleeding.  Under  full  treatment,  with 
ichthyol  internally  and  an  astringent  ointment,  the  bleeding 
ceased  and  the  mass  became  less  hard  and  smaller. 

But  a  month  or  so  later  he  had  some  fever,  and  I  visited  him 
in  another  city,  on  April  8,  in  consultation  with  his  physician. 
He  had  complete  obstipation,  tenesmus,  hiccough,  and  was 
greatly  prostrated  and  in  bed.  His  physician  urged  a  colostomy, 
to  which  I  did  not  agree,  and  with  active  treatment,  including 
tincture  of  colocynth,  2  drops  every  10  minutes,  he  came  out 
all  right,  so  that  on  April  20,  he  came  again  to  my  office. 

On  April  27,  I  sent  him  to  the  Memorial  Hospital,  thinking 
that  radium  might  perhaps  help  to  melt  away  the  tumor,  but  it 
was  thought  there  that  it  would  only  overstimulate  the  growth 
and  make  it  worse.  Some  of  the  masses  at  the  side  of  the  anus 
softened  and  were  allowed  to  break  and  discharge,  as  I  have 
always  found  that  when  such  were  lanced  the  wound  never 
healed,  but  left  a  raw,  increasingly  ulcerating  surface,  giving 
great  pain.  There  has  been  very  considerable  discharge  from 
several  of  these  openings,  one  or  more  of  them  closing. 

On  August  27,  he  said  that  he  "never  felt  better  in  his  life," 
but  on  the  28th,  he  drove  his  car  a  while,  and  that  night  had  a 
great  hemorrhage  from  that  region,  and  coming  from  the 
bathroom  fainted  and  fell  unconscious;  he  was  somewhat 
delirious  that  night,  the  bleeding  continuing  until  August  30. 
His  physician  then  gave  him  20  c.c.  of  Squibb's  Thrombo- 


CLINICAL  CONSIDERATIONS  AND  RESULTS  419 

plastin  in  a  glass  of  water,  which  stopped  the  bleeding  in  an 
hour,  but  the  doctor  said  that  he  could  not  live  2  days,  and 
gave  him  beef  soup  and  eggs  in  milk.  On  September  4,  I  went 
to  another  city  to  see  him,  and  found  him  better,  quite  bright, 
but  weak,  pulse  100,  he  had  slept  well.  I  gave  him  digalen.  5 
drops  increased  slowly  to  15,  every  3  hours.,  with  a  powerful 
alkaline  tonic.  On  September  15,  still  in  bed,  he  felt  and  looked 
very  much  better,  with  much  less  cachetic  appearance.  He 
had  had  no  more  hemorrhage  and  the  purulent  discharge  from 
the  openings  was  lessened.  On  October  6  I  saw  him,  sitting 
up  part  of  the  day,  and  he  remarked,  as  he  had  often  done, 
that  he  ''had  not  an  ache  nor  a  pain,''  and  on  Octover  13  was 
all  day  on  the  porch,  "feeling  very-  well." 

But  the  disease  progressed  internally,  and  he  finally  died 
peacefully  on  November  n,  9  months  after  his  first  visit,  and 
up  to  the  last  he  declared  that  he  had  not  an  ache  nor  a  pain 
but  only  felt  so  weak.     He  never  required  nor  took  any  opiate. 

Another  case  is  interesting,  although  I  was  not  able  to  follow 
it  many  months  after  there  had  been  great  improvement. 

Case  LXXIX  —  Cancer  of  the  rectum.  Mrs.  B.  C.  aged  31. 
with  quite  an  extensive  growth  in  the  rectum,  and  some  bleed- 
ing piles,  had  been  troubled  for  a  year,  and  had  recently  lost 
2  pounds;  she  was  greatly  constipated,  had  much  gas  in  the 
stomach,  saliva  acid,  and  had  had  bad  sleep  for  2  or  3  months, 
from  pain  low  down  in  the  back.  At  first  she  did  remarkably 
well,  and  said  she  felt  a  100  per  cent  better,  the  bleeding  piles 
being  controlled  by  ichthyol.  10  to  30  drops  internally,  well 
diluted  in  water,  half  an  hour  before  meals,  with  the  mixture  as 
given  to  others.  But  after  a  few  visits  she  was  lost  sight  of,  re- 
belling as  so  many  do  at  the  dietary  restrictions  and  the  pro- 
tracted treatment,  without  the  immediate  cure  of  her  disease. 

CANCER  OF  THE  KIDNEY,  BLADDER,  AND  PROSTATE 

Relatively  few  cases  of  cancer  in  this  region  appear  here, 
only  7,  two  females  and  five  males,  two  of  the  kidney,  males, 


420  CANCER 

three  of  the  bladder,  two  females  and  one  male,  and  two  of  the 
prostate.  The  youngest,  a  woman  of  32  with  the  disease  in  the 
bladder,  the  oldest  a  man  of  74,  with  cancer  of  the  prostate. 
Omitting  the  youngest  patient  the  average  was  61^2  years. 
There  were  three  known  deaths,  one  each  with  the  kidney, 
bladder,  and  prostate  affected.  All  the  cases  were  very 
interesting,  one  of  which,  with  post-operative  cancer  of  the 
kidney,  Case  XXXI,  is  still  living  and  is  very  well  and  flourish- 
ing, in  very  active  work,  under  continued  very  rigid  treatment. 
His  last  letter,  Dec.  21,  1920,  states  that  he  was  in  the  "best  of 
health  and  condition  that  I  have  known  for  many  years, "  and 
that  nearly  4  years  after  beginning  treatment.  If  our  proposi- 
tion to  patients  is  correct,  that  one  cannot  go  down  hill  in 
health  until  one  ceases  to  go  up  hill,  he  pretty  certainly  will 
not  die  of  cancer  if  he  maintains  his  present  course  of  living 
and  treatment — which  he  undoubtedly  will  do,  as  he  is  a  very 
intelligent,  educated  gentleman  and  a  most  faithful  patient. 
One  patient  with  cancer  of  the  bladder  has  also  been  reported, 
Case  XXXII,  who  is  still  alive  7  years  after  his  first  visit,  and 
active  in  business.  A  case  of  cancer  of  the  prostate  was  like- 
wise reported,  Case  XXX,  in  which  the  disease  had  apparently 
disappeared,  and  he  died  from  some  other  cause,  suddenly, 
many  months  after  he  was  first  seen. 

Case  LXXVIII. — Suprarenal  carcinoma.  Mr.  K.  C,  aged 
65,  first  seen  in  consultation,  in  Brooklyn,  Oct.  13,  1919.  He 
had  had  an  exploratory  laparotomy  in  a  New  York  Hospital 
in  April,  which  revealed  a  "large,  inoperable  hypernephroma 
of  the  right  kidney."  When  seen  he  was  very  weak,  in  bed 
having  lost  50  lb.,  suffering  greatly  and  under  morphine,  and 
it  did  not  seem  that  he  could  live  2  weeks.  Under  full  dietetic 
and  other  treatment,  with  considerable  aspirin  for  the  pain,  I 
heard  from  his  physician  on  October  31,  that  the  patient  was 
very  well,  sitting  up  and  eating  at  the  table,  and  had  no  pain, 
except  in  the  right  foot.  On  November  24,  I  was  amazed  to 
see  him  and  his  physician  walk  into  my  office,  coming  from 
Brooklyn,  6  weeks  after  my  first  visit  there.     He  was  sleeping 


CLINICAL  CONSIDERATIONS  AND  RESULTS  421 

fairly  and  had  taken  no  morphine  since  I  first  saw  him,  and 
had  very  little  pain,  except  when  lying  down.  The  bowels 
had  always  been  much  constipated,  and  he  had  some  trouble- 
some hemorrhoids,  for  which  I  gave  him  ichthyol  internally, 
as  mentioned  in  similar  cases,  and  on  December  22,  when  he 
called  again  at  the  office,  they  had  disappeared. 

On  Jan.  8,  1920,  I  saw  him  in  Brooklyn  because  of  terrific 
pain  in  the  left  leg,  the  one  on  the  opposite  side  from  the  hyper- 
nephroma, the  whole  sciatic  nerve  being  tender  on  pressure, 
and  painful  down  to  the  toes.  I  did  not  see  him  again  and 
learned  that  he  died  about  6  months  after  I  first  saw  him,  when 
we  did  not  think  he  could  live  2  weeks,  and  14  months  after 
the  real  trouble  was  revealed  by  exploratory  laparotomy. 

Case  LXXXI. — Carcinoma  of  the  bladder.  Mrs.  C.  J.  C, 
aged  72,  with  cancer  of  the  bladder,  seen  in  consultation  in  a 
neighboring  city,  Sept.  23,  1919.  The  disease  had  apparently 
begun  in  January,  with  urinary  trouble,  and  in  March  and 
April  she  had  passed  some  blood,  and  in  July  much  more,  with 
pain.  She  was  then  cystoscoped  and  a  fungating  neo-plastic 
mass  was  found  around  and  below  the  ureters.  For  the  last 
6  weeks  the  urine  had  passed  involuntarily,  and  for  10  days 
had  excoriated  the  external  parts  dreadfully.  She  was  always 
greatly  constipated,  was  very  cachectic  and  nervous,  and  with 
intensely  acid  saliva.  I  learned  that  she  died  suddenly,  no 
cause  being  given,  within  2  weeks  after  the  visit. 

Case  LXXXII. — Carcinoma  of  the  bladder.  Mr.  F.  C.  R., 
aged  51,  first  consulted  me  Sept.  7,  1920.  He  had  had  a  supra- 
pubic operation  for  what  was  called  papilloma  of  the  bladder 
on  Jan.  23,  1917,  followed  by  a  cauterization  of  the  base,  and  a 
24-hour  application  of  radium  2  weeks  later,  through  the  in- 
cision, and  also  in  the  rectum.  He  has  since  had  radium  used  a 
number  of  times.  His  health  seemed  very  much  better  until, 
in  June,  1918,  there  were  bladder  symptoms,  and  he  was  un- 
fortunately burned  in  the  bladder,  with  an  electric  cautery. 
On  Feb.  15,  1919,  the  deep  cautery  was  used  by  a  noted  urologist 
"to  burn  out  the  ulcer,"  and  since  that  time  until  May,  he 


42a  CANCER 

has  been  using  bladder  injections  daily,  of  permanganate  of 
potassium  alternated  with  a  solution  of  nitrate  of  silver. 

At  the  time  of  the  first  consultation  he  was  passing  urine 
every  two  or  three  hours  in  the  day  and  several  times  at  night, 
and  could  not  hold  3^  oz.  in  the  bladder  to  secure  a  specimen 
for  analysis.  The  urine  was  of  a  high  specific  gravity,  with 
high  acidity,  and  some  pus.  Placed  on  full  dietetic  and 
medicinal  treatment  the  improvement  was  marked  very  shortly. 
My  last  note  December  2 1  states  that  he  can  retain  8  oz.  of  urine  at 
one  time,  and  has  retained  it  as  long  as  6  hours,  and  usually 
goes  through  the  night  with  one  evacuation  of  urine.  The  total 
amount  passed  daily  during  the  preceding  30  days  had  varied 
from  35  to  62  oz.,  with  an  average  of  47^  oz.,  and  he  had  lost 
the  painful  sensation  he  had  had  after  voiding  urine.  It  is, 
of  course,  too  soon  to  make  any  final  judgment  of  the  case,  but 
with  other  experience  in  cancer  in  this  and  other  regions  it  is 
reasonable  to  expect  that  with  absolute  faithfulness  to  treatment 
he  will  remain  well.  He  now  weighs  181  pounds,  which  was  his 
normal  weight  before  the  trouble  begun,  he  doing  his  full  work 
as  lawyer  all  the  time. 

Case  LXXXIII. — Post-operative  cancer  of  the  bladder.  Mrs. 
B.  R.,  aged  32,  was  referred  to  me  for  treatment  by  her  physi- 
cian, Oct.  12,  1920.  Five  years  previously  she  had  had  some- 
thing wrong  with  a  pregnancy,  and  was  curetted,  and  has  had 
hemorrhage  and  pain  with  menstruation  since.  Six  weeks 
previous  to  her  visit  she  had  hysterectomy  and  ovariotomy 
performed,  and  there  was  then  found  a  cancerous  mass  on  the 
wall  of  the  bladder  which  was  left,  after  a  biopsy  was  taken. 
She  had  since  sharp  pain  in  the  left  loin.  A  later  communica- 
tion from  a  distant  city  stated  that  the  full  dietetic  and  medic- 
inal treatment  had  produced  " wonderful  improvement,"  and 
treatment  along  every  line  was  ordered  to  be  continued. 

CANCER  IN   OTHER  LOCALITIES 

In  this  group  were  placed  25  miscellanous  cases  of  cancerous 
lesions  on  various  parts  of  the  body,  some  of  them  primary 


CLINICAL  CONSIDERATIONS  AND  RESULTS  423 

lesions  of  carcinosis,  and  some  of  them  the  result  of  metastasis, 
many  of  them  of  very  considerable  interest.  There  were  seven 
females  and  18  males,  whose  ages  ran  from  24  to  80  years,  with 
eight  who  were  69  or  more  years  old.  Four  were  recorded  as 
having  died,  and  four  were  cured.  These  cases  relate  to  carci- 
noma on  the  back  of  the  hand,  five  instances,  two  from  #-rays, 
axilla,  shoulder,  abdomen,  thigh,  leg,  foot,  and  nine  on  the 
penis.     Some  of  the  more  interesting  cases  may  be  alluded  to. 

Case  LXXXIV. — Mr.  B.  H.  C,  aged  74,  seen  first  on  Mar.  10, 
19 19.  He  had  long  had  a  roughened,  warty  condition  on  the 
back  of  the  right  hand,  which  began  to  be  active  about  a  year 
before  his  visit,  and  for  the  previous  3  to  4  months  had  grown 
to  its  present  state,  having  been  cauterized.  When  seen  there 
was  a  patch  about  an  inch  in  diameter,  raised  about  3i$  of  an 
inch,  hard,  with  characteristic  edges,  and  covered  with  a  moder- 
ate crust,  which  continually  reformed  when  knocked  off.  The 
strong  thorium  paste  was  freely  applied  over  all,  with  a  wire 
vaccination  shield  to  protect  the  same,  which  was  worn  all  the 
time  until  on  August  24,  when  the  surface  was  normal.  There 
had  been  about  a  dozen  applications  of  the  paste,  at  intervals  of 
from  one  to  two  weeks,  according  as  the  crust  formed  was  still 
adherent  or  loose. 

Case  LXXXV. — Cancer  of  the  axilla  following  removal  of 
same  on  the  hand.  Mr.  C.  W.  R.,  aged  59,  had  a  warty  growth 
on  the  back  of  the  right  hand,  2  years  before  his  visit  July  20, 
191 7.  One  year  later  this,  which  had  grown,  was  removed 
surgically,  together  with  glands  which  had  formed  in  the 
axilla,  in  October,  19 16.  On  Feb.  12,  191 7,  the  glands  in  the 
axilla,  which  had  returned,  were  removed,  and  he  had  also  #-ray 
treatment.  When  he  called  the  right  arm  was  greatly  swollen, 
and  there  was  an  enormous  mass  of  characteristic,  ulcerating 
tissue  filling  the  axilla  and  keeping  the  arm  more  or  less  extended. 
The  saliva  was  strongly  acid,  and  the  bowels  were  constipated, 
he  depending  on  medicine.  He  was  placed  on  full  dietetic  and 
medicinal  treatment,  but  little  could  be  expected  in  such  a 
condition,  and  he  was  soon  lost  sight  of. 


4-M  CANCER 

Case  LXXXYI. — Possible  primary  cancer  of  the  axilla.  Mrs. 
K.  R.  A.  H.,  aged  67,  first  noticed  a  small  enlarged  gland  in  the 
left  axilfa,  slightly  painful,  about  7  months  before  I  was  con- 
sulted May  18,  1920.  This  was  removed  surgically  on  Oct.  20, 
1919,  3  or  4  weeks  after  it  was  detected;  with  several  courses  of 
a;-ray  treatments  thereafter.  After  the  operation  the  left  arm 
was  very  much  swollen,  involving  the  whole  forearm  and  hand, 
which  has  gone  down  somewhat  but  not  entirely,  with  #-ray 
treatment,  but  since  being  placed  on  full  dietary  and  medicinal 
treatment,  her  son,  who  is  a  physician  writes  that  it  has  returned 
to  normal,  which  he  attributes  to  the  treatment,  which  "had 
worked  wonders  for  her,  so  far."  Neither  before  the  operation, 
nor  some  months  after,  have  they  been  able  to  discover  "any 
other  focus  of  carcinoma  in  any  other  organ,  and  it  seems  as  if 
the  axillary  glands  were  the  primary  seat." 

Case  LXXXVII. — Metastatic  cancer  of  the  hip  bone.  Mrs. 
C.  J.,  aged  37,  was  first  seen  April  22,  1920.  She  had  had  one 
exploratory  operation  at  a  New  York  Hospital  3  years  previous- 
She  was  told  that  she  had  a  tumor  at  the  neck  of  the  womb, 
too  far  gone  to  operate  upon,  and  was  sent  to  the  Memorial 
Hospital,  and  apparently  cured  by  3  or  4  treatments.  But 
for  the  past  several  months  she  had  had  symptoms  pointing  to 
the  left  hip,  with  spasmodic  pains  and  contraction  of  the 
muscles,  and  for  about  3  weeks  had  been  in  bed.  She  was 
cachectic,  with  a  poor  appetite,  pulse  135,  and  she  succumbed 
within  2  months.  There  were  probably  metastases  elsewhere 
as  well. 

Case  LXXXVIIL— Carcinoma  of  the  left  thigh.  Mrs.  S.  B., 
aged  70,  two  years  previous  to  the  visit  had  injured  the  back 
of  the  middle  of  the  left  thigh  on  a  barrel  hoop,  and  the  sore 
had  never  healed,  although  treated  with  ointments,  etc.  When 
seen,  Apr.  15,  1920  there  was  a  deeply  ulcerated  mass  of  can- 
cerous tissue  4  by  6  in.  in  diameter,  on  the  outside  and  back  of 
the  middle  of  the  left  thigh,  with  hard,  typical  edges,  and  two 
very  large  and  hard,  and  not  painful  glands,  in  the  groin.  Very 
much  comfort  and  improvement  was  realized  by  careful  internal 


CLINICAL  CONSIDERATIONS  AND  RESULTS  425 

measures,  together  with  a  continuous  application  of  a  carbolized 
calamine  and  zinc  ointment,  spread  on  very  thin  pledgets  of 
absorbent  cotton;  but  the  disease  overcame  her  and  she  died 
not  so  very  long  after. 

There  were  nine  cases  of  carcinoma  of  the  penis,  mainly  on  the 
glans,  some  of  which  were  very  severe  and  distressing;  the 
ages  ran  from  24  to  76,  with  an  average  of  52  years.  One  of 
them  was  particularly  interesting,  because  of  its  duration  and 
the  complete  cure  by  operation,  observed  nearly  five  years 
thereafter. 

Case  LXXXIX. — Carcinoma  of  the  penis.  Mr.  H.  A.  G., 
aged  47,  made  his  first  visit  on  Aug.  8,  191 2.  For  3  or  4  years 
he  had  had  some  disease  beneath  the  foreskin,  which  had  become 
very  troublesome  6  months  before  his  visit.  It  was  thought  to 
be  syphilitic,  and  he  took  mixed  treatment  for  3  months 
without  result.  The  lesion  was  then  scraped  on  June  7  by  a 
specialist  in  another  city,  and  it  was  thought  that  spirochete 
were  found  in  the  scrapings,  and  he  was  given  salvarsan  intra- 
venously. On  July  4,  there  was  another  dose  of  salvarsan, 
and  the  sore  seemed  to  heal  up  in  10  days,  but  a  week  before 
his  visit  it  was  again  sore,  and  was  cauterized  by  his  family 
physician. 

When  seen  there  was  a  characteristic  epidermoid  carcinoma, 
involving  nearly  half  the  glans,  with  much  infiltration  and 
deeply  eroded,  and  very  painful,  for  which  he  took  morphine. 
He  was  treated  with  an  emollient  ointment  and  internal  meas- 
ures for  6  weeks,  when  the  sore  was  partially  healed  by  Septem- 
ber 19,  but  it  was  then  quite  hard  and  characteristic  of  epithe- 
loma,  with  everted  edges  and  abundant  granulations.  There 
was  no  pain  and  he  had  abandoned  the  opiate,  sleeping  well. 
On  September  25  there  was  a  very  complete  operation  per- 
formed, under  my  direction,  with  amputation  at  the  base  of  the 
penis,  and  thorough  cleaning  out  of  the  enlarged  glands  in  both 
groins.  Later  he  was  worried  about  the  former  diagnosis  of 
syphilis,  and  two  Wasserman's  were  taken  by  two  different 
serologists,  and  both  were  negative,  and  the  excised  lesion  had 


426  CANCER 

been  examined  microscopically  and  found  to  be  carcinomatous. 
On  Feb.  3,  191 7,  he  presented  himself  for  examination  and  there 
was  a  perfect  result,  with  no  recurrence,  four  years  and  6 
months  after  his  first  visit.  How  much  of  the  unfortunate 
result  in  this  case  was  due  to  the  mistaken  diagnosis  and  the 
repeated  scraping  and  cauterization,  cannot  be  decided,  but  it 

teaches  a  lesson. 

SARCOMA 

There  were  46  patients  with  sarcoma  in  various  locations  and 
with  different  degrees  of  severity,  whose  ages  ran  from  6  years 
to  eighty.  The  advanced  ages  of  many  of  the  patients  was 
unexpected,  for,  leaving  out  that  of  the  youngest,  6  years,  the 
average  age  of  all  was  just  50  years,  contrary  to  what  is  gener- 
ally expected  in  sarcoma :  there  were  only  9  of  40  or  less  years 
of  age. 

The  youngest  patient,  a  boy  of  6,  ultimately  died  with  a  large 
tumor  over  the  sacrum;  the  oldest,  aged  80,  had  a  great 
metastatic  mass  by  the  left  jaw,  from  pigmentary  lesions  above, 
irritated  by  shaving,  ten  years  before.  There  were  11  cases, 
7  males  and  4  females  with  the  disease  in  the  mouth  and  jaws, 
4  with  multiple  non-pigmented  sarcoma,  1  male  and  3  females, 
and  13  cases  of  melano-sarcoma,  one  of  them,  a  most  striking 
case,  with  comple  recovery,  has  already  been  recorded,  Case 
XVII:  two  others  are  worthy  of  special  record. 

Case  XC. — Melano-sarcoma  of  the  lower  leg.  Mrs.  L.  H., 
aged  50,  seen  in  a  county  town,  Sept.  1,  19 18.  For  2  or  3 
years  there  had  been  developing  on  the  right  lower  leg, 
about  the  middle  and  outer  aspect,  a  tumor  somewhat  dark 
in  color,  which  gave  her  no  particular  trouble,  except  some 
aching  when  long  standing.  She  was  being  treated  for  an 
eczema  of  some  duration  when  this  was  incidently  mentioned. 
On  examination  there  was  a  mass  about  an  inch  in  diameter, 
raised  half  an  inch  or  so,  and  of  a  dark,  purplish  color.  Dr. 
H.  H.  Janeway  saw  her  with  me  and  confirmed  the  diag- 
nosis of  melano-sarcoma  and  very  strongly  urged  that  she  go  at 
once  to  the  Memorial  Hospital,  for  radium  treatment,  predict- 


CLINICAL  CONSIDERATIONS  AND  RESULTS  427 

ing  that  it  would  prove  very  serious  if  neglected  or  removed 
surgically,  as  there  were  enlarged  inguinal  glands.  This  we 
expected  that  she  should  do. 

For  her  eczema,  and  for  this,  she  was  placed  under  rigid 
vegetarian  diet,  and  given  an  acetate  of  potassa,  nux,  cascara, 
and  rumex  mixture.  The  next  summer  I  saw  her,  in  the 
country,  and  the  eczema  had  vanished,  and  she  thought  little 
of  the  leg  trouble,  which  was  in  about  the  same  condition,  she 
had  not  taken  the  radium  treatment,  or  any  other  than  as 
prescribed,  as  she  could  not  well  come  to  the  city.  When  last 
seen,  on  Sept.  19,  1920,  over  2  years  after  the  first,  the  mass 
was  only  a  little  larger,  projecting  a  little  further,  and  had 
given  her  no  particular  annoyance.  The  result  in  this  case  is 
striking,  especially  in  contrast  with  the  next  one. 

Case  XCI. — Melano-sarcoma  of  the  left  hip.  Mrs.  T.  E.  J. 
aged  66,  had  been  treated  by  me  in  1888  for  eczema,  which 
yielded  shortly  and  remained  well,  and  then  at  intervals  for 
other  troubles,  and  then  not  for  a  long  time.  On  Feb.  20 
1920,  she  came  to  me  for  a  minor  skin  trouble,  and  rather 
incidentally  mentioned  a  pigmented  lesion  on  the  left  hip, 
which  had  existed  for  5  years;  but  for  the  past  year  it  had 
developed  slowly  into  a  flat,  slightly  raised  mass,  which  annoyed 
her  by  itching. 

When  seen  there  was  a  black  tumor,  about  a  half  an  inch  in 
diameter  and  raised  }^  inch  with  a  little  moisture  beneath  it, 
from  scratching.  As  she  was  a  lady  of  position  and  means,  I 
disliked  to  take  the  responsibility  of  the  case  alone,  and  sent 
her  to  a  very  prominent  surgeon  for  consultation.  He  recog- 
nised it  as  a  melano-sarcoma,  with  enlarged  inguinal  glands, 
and  strongly  advised  immediate  removal  of  the  primary  growth 
and  the  inguinal  lymph-nodes,  but  considered  the  "out-look 
as  certainly  very  bad."  He  operated  on  March  29,  and 
confirmed  the  diagnosis  by  microscopic  sections.  I  saw  her 
socially  a  few  weeks  after  the  operation,  she  still  being  confined 
to  her  room,  when  she  seemed  fairly  well,  but  I  learned  that 
she  died  within  4  months  thereafter. 


428  CANCER 

There  have  now  been  presented  the  more  or  less  full  clinical 
histories  of  over  go  cases  of  malignant  disease,  besides  the 
incidental  mention  of  some  others;  these  all  are  from  among 
still  many  others  of  like  character  mostly  all  illustrating  to  a 
greater  or  less  degree  the  value  of  a  faithfully  carried  out  proper 
dietetic,  medical,  and  local  treatment,  in  both  early  and  late 
cancer. 

Among  these  have  been  some  terrible  cases,  post-operative 
and  inoperable,  which  have  exhibited  the  value  of  this  line  of 
procedure  in  an  interesting  manner,  both  in  ameliorating  suf- 
fering and  in  prolonging  life,  with  some  cures,  while  the  results 
in  early  cases  have  been  most  gratifying. 

Among  the  91  cases,  here  recorded,  more  or  less  fully,  there 
were  26  known  deaths  from  the  disease,  besides  3  which  were 
probably  fatal,  a  total  of  29  in  all.  But,  of  course,  there  were 
very  many  more  not  traced,  among  far  advanced  cases  seen 
once  or  twice,  or  in  consultation.  There  were  35  regarded 
as  clinically  cured,  that  is  all  recognizable  signs  and  symptoms 
of  cancer  had  disappeared.  Some  were  known  to  be  well  and 
free  from  disease  for  16  years,  others  for  5  years  and  more. 
Many  more,  of  more  recent  date  were  recorded  as  so  im- 
proved or  greatly  improved  that  in  the  light  of  experience  it 
is  expected  that  all  will  go  well,  if  they  will  continue  to  follow 
all  directions  as  conscientiously  as  has  been  the  case  with  others. 
Of  those  who  died  such  an  end  was  inevitable  when  first 
seen,  in  many  of  them,  but  their  records  show  a  course  very 
different  from  that  commonly  observed  in  such  cases,  and 
most  of  them  passed  away  peacefully,  without  pain  and  not 
requiring  or  taking  any  morphine  or  opiates. 

Among  the  entire  number  of  patients,  229,  with  neoplastic 
disease,  recorded  during  the  past  4  years,  since  statistics  were 
last  given,  there  were  52  known  deaths,  including  the  29  men- 
tioned above,  among  the  histories  given.  But,  as  already 
remarked,  there  must  have  been  very  many  more,  for  it  is 
very  difficult  in  a  busy  private  practice  to  follow  up  patients 
when  they  do  not  call  as  directed.  Some  of  the  cases,  of  course, 
are  too  recent  to  enter  at  ail  into  statistics. 


CLINICAL  CONSIDERATIONS  AND  RESULTS  429 

Of  the  24  cases  of  undoubted  primary  cancer  of  the  breast 
whose  histories  have  been  given,  there  were  8  patients  who 
were  known  to  have  recovered  clinically  for  over  or  about  the 
5-year  period,  several  being  watched  for  about  16  years,  per- 
fectly well,  and  there  is  no  reason  to  expect  recurrence  of  the 
cancerous  trouble,  if  with  proper  care  they  persist  in  the  meas- 
ures which  have  removed  the  neoplasm.  There  were  also  more 
than  that  number  who  had  been  clinically  well  from  1  to  4 
years,  with  every  prospect  of  remaining  well  if  they  persisted 
faithfully,  as  they  had  done,  in  all  the  necessary  measures; 
there  are  also  many  others  in  whom  the  progress  has  been 
favorable  up  to  the  present  time,  which  will  probably  continue, 
if  they  are  faithful  to  treatment.  All  this  is  on  a  very  different 
basis  from  that  of  surgery,  or  even  of  #-ray  and  radium,  which 
may  remove  more  or  less  of  the  accessible  products  of  carci- 
nosis, leaving  the  real  cause  of  the  disease  to  produce  new 
lesions,  possibly  at  a  late  date ;  even  as  tuberculosis  will  remain 
absent  indefinitely  under  proper  conditions,  but  will  recur  with 
a  recurrence  or  continuance  of  the  elements  allowing  the  first 
lesions  to  develop. 

Four  of  the  patients  with  primary  cancer  of  the  breast  died, 
one  suddenly  at  85  years,  one  at  68,  who  came  with  an  enor- 
mous, absolutely  inoperable  mass,  one  aged  53  quite  similar,  and 
one,  aged  36,  with  general  carcinosis  after  removal  of  the  breast 
by  chemical  procedure,  as  described  already.  All  of  these  had 
been  declared  inoperable,  by  surgeons,  before  coming  for  treat- 
ment. There  were  10  post-operative  cases  detailed,  three  of 
them  were  known  to  have  died,  peacefully,  without  morphine, 
and  four  were  greatly  improved  when  last  seen. 

There  were  six  absolutely  inoperable  cases  of  cancer  of  the 
uterus,  of  whom  three  recovered  completely,  whose  histories 
have  been  detailed,  two  now  for  almost  4  years,  and  two  died, 
and  one  is  too  recent  to  report  on,  but  improving.  Time  and 
space  do  not  permit  of  analyzing  the  balance  of  the  cases,  which, 
however,  are  well  worthy  of  consideration. 

Clinical  experience,  therefore,  and  the  results  obtained,  con- 


430  CANCER 

firm  abundantly  what  has  preceded  in  regard  to  the  constitu- 
tional nature  and  the  value  of  intense  medical  treatment,  as 
intimated  in  the  opening  sentences  of  this  chapter.  Did  space 
permit  the  number  of  these  illustrative  histories  could  be  in- 
creased materially,  although,  naturally,  the  most  striking  in- 
stances have  been  selected.  Much  confirmation  could  also  be 
given  by  the  written  testimony  of  many  physicians  and  surgeons 
who  have  made  trial  of  this  mode  of  procedure,  while  any 
amount  of  testimony  could  be  adduced  by  those  who,  in  print 
or  otherwise,  have  acknowledged  the  futility  of  surgical  opera- 
tions in  really  curing  cancer.  All  knowledge  and  experience, 
therefore,  seems  surely  to  point  to  the  wisdom  of  not  ignoring  a 
proper  medical  consideration  and  treatment  of  the  disease  car- 
cinosis, and  of  not  simply  attempting  to  attack  only  its  mani- 
festations in  different  parts  of  the  body,  surgically  or  otherwise, 
except  as  an  adjunct  to  proper  medical  treatment. 


CHAPTER  XIX 
CONCLUSIONS 

In  the  light  of  all  that  has  been  presented  in  the  preceding 
pages  what  must  be  concluded  in  regard  to  the  nature  and 
proper  treatment  of  cancer?  What  is  the  real  cancer  problem  ? 
For  it  has  been  abundantly  shown  by  statistics  and  otherwise 
that  the  hitherto  accepted  theory  and  view  of  its  purely  local 
nature  and  treatment  have  resulted  only  in  a  steadily  increasing 
morbidity  and  mortality  of  cancer,  with  all  the  miseries  and 
uncertainties  of  surgical  operations,  and  the  pain  and  distress 
and  fatality  of  recurrent  manifestations  of  the  disease;  and 
even  the  ultimate  shortening  of  life  in  the  average,  as  claimed 
by  many. 

Laboratory  research,  with  its  enormous  expenditure  of  time, 
money,  energy,  and  animal  life  has  proved  an  utter  failure  in 
solving  "The  Cancer  Problem,"  as  far  as  adding  materially  to 
our  intrinsic  knowledge  of  the  disease,  or  in  the  way  of  lessening 
its  morbidity  and  mortality.  Nor  have  the  various  Societies 
for  the  study  and  prevention  of  cancer  accomplished  anything 
practical  in  regard  to  its  prophylaxis  or  cure,  and  have  certainly 
not  lessened  its  ravages. 

Propaganda  in  regard  to  the  necessity  for  the  very  early  and 
complete  extirpation  of  all  suspected  cancerous  and  precancer- 
ous lesions,  have  been  shown  by  United  States  statistics  to  have 
more  than  doubled  the  percentage  of  deaths,  in  the  year  of 
greater  surgical  activity  which  followed  this  special  appeal 
throughout  the  country. 

During  all  this  period  of  the  intense  study  of  cancer  in  the 
laboratory,  and  of  surgical  zeal,  the  mortality  of  tuberculosis, 
under  wise  medical  supervision  has  fallen  about  30  per  cent, 
since  1900,  while  that  of  cancer  has  risen  by  about  the  same  30 

431 


432  CANCER 

per  cent.  The  mortalities  of  the  two  diseases  have,  therefore, 
approached  one  another  almost  60  per  cent,  and  at  this  rate  in 
20  years  more  the  death  curve  of  the  two  will  have  more 
than  crossed  one  another,  unless  something  occurs  to  produce  a 
change  in  the  method  of  handling  these  two  diseases.  Indeed, 
in  New  York  City,  during  5  particular  weeks,  in  1920,  the 
deaths  from  cancer,  according  to  the  weekly  reports  of  the 
Board  of  Health,  have  actually  been  more  than  those  from 
tuberculosis,  and,  as  we  have  seen,  during  the  last  6  months 
of  1920  the  deaths  from  cancer  actually  exceeded  those  from 
tuberculosis,  by  twenty-two. 

What  then  is  to  be  done?  Shall  the  world  go  blindly  ahead 
with  the  accepted  dictum  that  "we  know  nothing  of  the  cause 
of  cancer,"  and  pursue  a  course  of  treatment  under  which  the 
death  rate  has  so  steadily  and  alarmingly  increased,  or  shall  we 
have  minds  open  to  conviction?  It  is  by  no  means  claimed 
that  the  goal  has  been  reached,  nor  that  we  know  fully  the  real, 
absolute,  and  ultimate  cause  of  cancer,  any  more  than  we 
know  absolutely  the  final  cause  of  many  other  diseases,  which 
are  treated  more  or  less  successfully.  We  do  know  enough  now, 
however,  to  begin  with  at  least,  for  nothing  could  be  worse  than 
the  commonly  recognized  and  acknowledged  90  per  cent  of 
ultimate  deaths  from  the  disease  in  those  once  affected  with 
cancer,  under  surgical  management,  while  that  of  the  cases  here 
analyzed  has  been  very  much  less  under  medical  management. 

In  order  that  the  subject  of  the  constitutional  nature  and 
treatment  of  cancer  might  be  readily  understood  and  grasped, 
a  synopsis,  which  I  have  already  repeatedly  presented,  was  given 
in  the  first  chapter,  to  cover  as  far  as  possible  the  essential 
matters  to  be  brought  out  in  later  pages.  And  now  in  con- 
clusion these  are  especially  referred  to  as  illustrating  what  the 
laboratory  has  furnished  negatively  and  positively,  to  demon- 
strate that  cancer  is  not  a  local  disease,  but  one  of  constitutional 
origin  and  nature,  together  with  the  confirmation  of  this  fact 
from  statistical  and  clinical  evidence. 

In  regard  to  no  other  bodily  ailment  has  there  been  such  an 


CONCLUSIONS  433 

imperious  and  insistent  demand  for  the  establishment  of  an 
absolutely  definite  cause  of  disease,  proven  by  laboratory  re- 
search and  experimental  procedures,  as  in  the  case  of  cancer. 
This  is  due  to  the  long  prevailing  and  narrow-minded  view  which 
has  been  held  as  to  its  local  nature,  and  until  some  definite  cause 
is  fully  proven,  the  skepticism  which  has  existed  will  probably 
still  continue  to  exist,  for  a  while,  in  the  minds  of  many,  namely 
that  no  cause  can  possibly  be  proved  otherwise.  It  is  here 
frankly  acknowledged  that  the  exact  and  precise  metabolic  con- 
ditions causing  this  disease  have  not  yet  been  definitely  fixed 
upon,  and  possibly  will  never  be  capable  of  actual  laboratory 
demonstration.  And  yet  it  has  been  shown  by  many  cases  that 
by  proceeding  along  this  line  of  study  and  treatment,  results 
have  been  obtained  in  many  directions  which  greatly  surpass 
those  commonly  seen.  And  if  the  many  other  practitioners 
who  have  obtained  similar  results  from  proper  diet  and  medical 
treatment,  could  speak,  it  would  be  thoroughly  convincing. 
Moreover,  if  the  real  truth  could  be  told,  it  would  be  found  that 
physicians  and  surgeons  pretty  unanimously  recognize  the  fact 
that  heretofore  the  profession  has  not  gotten  on  the  right  track 
concerning  the  nature  and  proper  treatment  of  cancer. 

It  is  not  at  all  claimed  that  "the  cancer  problem"  has  been 
fully  solved,  but  "the  real  cancer  problem"  is  here  presented 
for  further  study  and  elaboration,  by  close  observation  upon  the 
human  subject,  conjoined  with  proper  laboratory  work. 

As  in  the  treatment  of  other  diseases  many  remedies  and 
measures  may  be  required,  singly,  combined,  or  alternately, 
each  contributing  its  share  to  a  successful  result,  so  undoubtedly 
in  cancer  many  different  lines  of  treatment  may  be  used  with 
advantage,  conjointly  or  in  succession.  While  "the  day  of 
cancer  surgery  is  past.  There  is  nothing  in  it,"  as  an  eminent 
pathologist  has  remarked,  it  is  conceivable  that  occasions  may 
arise  when  some  surgical  procedure  is  advisable,  for  the  prompt 
removal  of  a  seriously  offending  cancerous  mass,  but  not  with 
the  expectation  of  curing  the  disease:  and  operative  surgery 
may  possibly  be  called  for  occasionally,  in  certain  rare  cases. 


434  CANCER 

We  have  seen  that  the  g-ray  and  radium  have  been  effective 
in  causing  to  disappear,  even  permanently,  certain  very  local 
epithelial  derangements,  such  as  cutaneous  epithelioma,  and 
also  that  their  skillful  use  may  possibly  affect  some  deeper,  true 
cancerous  lesions  favorably.  But  when  more  or  less  metastasis 
has  taken  place  they  are  either  helpless  or  afford  only  temporary 
benefit.  Moreover,  many  candid  workers  along  this  line  ac- 
knowledge that  their  effect  is  only  local,  like  surgery,  and  that, 
it  does  not  and  cannot  reach  and  remove  the  real  cause  of,  or 
cure  true  carcinoma.  But  proper  radiation  does  mark  a  dis- 
tinct advance  in  the  conflict  with  cancer,  and  should  certainly 
be  skillfully  used  when  possible,  in  certain  cases,  as  an  adjunct 
in  overcoming  some  of  the  local  results  or  products  of  the  car- 
cinosis, carcinomatous  dyscrasia,  or  disease. 

In  like  manner  sero-therapy,  of  one  kind  or  another,  has  been 
reliably  shown  to  have  had  a  favorable  action  in  a  certain  small 
proportion  of  cases  of  cancer,  even  those  which  seemed  inoper- 
able and  hopeless.  But  one  after  another  of  these  measures 
has  been  abandoned  as  practically  useless  or  infeasible,  and 
as  not  at  all  reaching  and  removing  the  true  basic  cause  of  the 
disease.  The  only  possible  exception  to  this  is  the  one  last 
mentioned,  by  repeated  injections  of  foreign  vegetable  pro  teals; 
this  treatment  approaches  the  line  of  thought  presented  in  these 
pages,  namely  the  relation  of  cancer  to  the  imperfect  breaking 
up  and  assimilation  of  the  elements  of  protein  in  the  system. 
So  that  this  line  of  treatment  has  also  a  distinct  indication  in 
regard  to  the  disease  cancer,  or  carcinosis,  of  which  the  local 
lesion  which  we  call  cancer  is  the  product,  and  this  may  and 
perhaps  should  be  employed  in  connection  with  any  or  all  of 
the  other  measures  which  have  been  found  of  service. 

Organotherapy  is  still  in  its  infancy  and  no  correct  judgment 
can  be  yet  formed  as  to  what  part  it  may  eventually  take  in 
checking  carcinosis,  or  removing  its  manifestations.  Undoubt- 
edly the  ductless  glands  play  an  important  part  in  the  conduct 
of  metabolism,  and  in  the  life  processes  of  the  system,  as  we 
have  seen  in  a  former  chapter,  and  they  seem  to  have  a  syner- 


CONCLUSIONS  435 

getic  action  on  each  other;  they  also  affect  the  operation  of  the 
larger  organs  and  the  condition  of  the  blood,  and  consequently 
influence  the  healthy  or  diseased  action  of  all  the  cells  of  the 
body. 

But  it  is  not  yet  determined  exactly  what  part  each  of  the 
endocrinous  glands  play,  or  whether  disorder  comes  from  ex- 
cessive or  insufficient  action  of  any  or  all  of  them,  so  that  for 
the  present  our  knowledge  of  this  line  of  practice  is  rather  ex- 
perimental and  empiric.  Thus  far,  to  my  knowledge,  there  is 
only  one  of  them,  the  thyroid,  which  has  been  widely  acknowl- 
edged to  have  any  very  distinct  influence  in  connection  with 
cancer,  and  our  knowledge  of  this  is  almost  wholly  clinical. 
But  the  experience  of  many,  including  myself,  is  that,  when 
rightly  used,  proper  preparations  of  animal  thyroid  are  of 
decided  service  in  many  cases  of  cancer,  especially  in  subjects 
exhibiting  adiposity,  in  whom  the  disease  always  tends  to  do 
badly.  So  that  thyroid  treatment  may  and  should  be  used 
in  many  cases,  in  conjunction  with  other  proper  measures, 
already  indicated;  for  it  acts  along  the  same  lines  of  modifying 
and  restoring  to  the  normal  state  a  blood  current  which  will  so 
nourish  all  the  cells  of  the  body  that  none  of  them  will  rebel 
and  run  riot,  as  in  our  illustration  of  a  mutiny  in  a  regiment  or 
on  shipboard,  from  insufficient  or  poorly  prepared  nutriment. 
It  has  been  abundantly  shown  in  other  chapters,  however,  that 
the  basic  element  of  the  successful  treatment  of  cancer  must 
always  rest  upon  the  proper  supply  of  correct  alimentation:  if 
this  is  wrong  all  other  treatment  is  ineffective. 

Having  covered  all  the  means  thus  far  commonly  employed 
in  the  treatment  of  cancer,  and  finding  such  limitations  in  ulti- 
mate service  in  regard  to  each  and  all  of  them,  what  conclusion 
must  we  finally  come  to?  There  is  only  one.  Thus  far  the 
profession  has  not  succeeded  in  checking  the  morbidity  and 
mortality  of  the  disease  because  investigators  have  long  been 
mainly  on  the  wrong  track,  and  our  ideas  as  to  the  true  nature 
of  cancer  must  be  radically  changed  if  we  wish  to  diminish  its 
morbidity  and  mortality. 


436  CANCER 

Led  by  honest,  industrious,  intelligent,  and  capable  patho- 
logical workers,  cancer  has  been  regarded  as  a  local  disease, 
whereas  it  has  been  abundantly  shown  and  declared  by  any 
number  of  good  clinical  observers  that  it  is  a  constitutional  one, 
quite  as  much  as  is  gout,  and  many  other  affections.  In  the 
latter  the  derangement  of  tissues  takes  an  inflammatory  form 
or  character,  and  in  the  former,  cancer,  a  neoplastic  one,  both 
of  them  from  an  erroneous  pabulum,  a  faulty  blood  and  lymph 
stream  furnished  to  the  cells.  Exactly  why  this  is  so  we  may 
perhaps  never  know:  indeed  we  now  know  little  more  about 
the  true,  actual  pathogenesis  of  gout  than  we  do  about  that  of 
cancer;  but  experience  has  taught  us  how  to  reach  the  former 
by  correct  dietetic,  hygienic,  and  medicinal  measures,  and  many 
of  us  have  learned  the  same  about  cancer,  with  gratifying  results, 
as  has  been  shown  in  the  preceding  pages. 

The  logic  of  the  whole  situation  is  to  accept  what  has  been 
shown  to  be  reasonably  correct  and  of  advantage  in  all  lines  of 
procedure,  and  to  adapt  them,  singly  or  conjointly,  to  individual 
cases,  remembering  always  that  probably  there  never  can  be 
any  one  single  or  simple  cure  for  cancer,  such  as  quinine  for 
malaria,  mercury  for  syphilis,  or  even  antitoxin  for  diphtheria 
(for  cancer  is  not  a  microbic  affection).  But  back  of  all  other 
measures  there  must  be  a  correct  diet  and  mode  of  living,  and 
correct  action  of  the  whole  system,  furnishing  a  correct  blood 
stream  for  the  proper  nourishment  of  every  cell  of  the  body; 
for  proper  nutrition  is  the  basis  of  health.  Then  there  will  be 
no  rebellion  or  mutiny  of  cells,  with  its  sad  consequences,  which 
are  familiar  to  all. 

When  exactly  the  proper  nutrition  is  restored,  and  the  cells 
receive  a  correct  pabulum,  we  find  that  the  aggregation  of 
riotous  cells,  whether  in  the  original  lesion  of  cancer  or  in 
metastases,  disperse  and  return  to  their  normal  function,  as 
would  mutinous  soldiers  or  sailors  when  their  rations  were 
made  adequate  and  attractive.  But,  as  with  a  return  to  bad 
sanitary  or  dietetic  conditions  there  would  be  again  mutinous 
action  in  the  latter,  even  so  there  will  be  a  recurrence  of  the 


CONCLUSIONS  437 

cancerous  lesion,  if  there  is  a  continuance  of  the  same  bad 
blood  conditions  which  first  caused  certain  normal  cells  to  give 
up  their  allegiance  to  physiological  control  and  to  combine  in 
neoplastic  groups  of  malignant  character. 

Therefore,  one  who  would  intelligently  and  successfully  treat 
malignant  disease  must  have  broad  medical  knowledge  and 
experience,  with  medical  acumen,  and  apply  the  same  vigor- 
ously to  the  study  of  the  individual  patient,  with  patience  and 
great  perseverance.  He  must  also  keep  abreast  with  advances 
made  in  surgery,  radiation,  serotharapy,  thermotherapy,  chem- 
ical extirpation  and  any  and  all  measures  which  may  be  of 
service  at  any  time  in  favorably  acting  on  the  immediate 
products  of  the  disease  carcinosis. 


INDEX 


Abderhalden,    defensive   ferments   in 
cancer,  142 
extracts  of  tumor  tissue  in  pro- 
teolysis, 73 

Abernethy,    constitutional    nature   of 
cancer,  87,  162 

Absence  of  cancer  in  slavery  times,  226 

Acanthoma,  42,  43 

Acanthosis  nigricans,  1 73 

Acid,  body,  reaction  in  cancer,  67 

Acidity  of  organs  and  cancer,  195 
of  urine  in  cancer,  149 

Acidosis  in  cancer,  133,  145, 
judged  by  the  urine,  149 

Acinar  carcinoma,  58 

Action  of  x-rays  and  radium  much  the 
same,  263 

Active    immunization,    dangerous  in 
cancer,  287 

Adeno-carcinoma  of  breast,  57 
of  stomach,  44 

Adenoma,  relation  to  cancer,  169 

Aebli,  results  of  operations  on  cancer, 

105 
Africa,  cancer  in,  21,  35,  36,  227 
Agamogenesis,  12 
Age,  cancer,  158 

deaths  in  United  States  by,  226 
in  relation  to  cancer,  192,  224 
Agnew,  value  of  operations  in  cancer, 

230 
Aims  of  surgery  in  cancer,  112 
Albuminuria  in  cancer,  133 
Alcohol  and  cancer,  211 
Alimentary  tract,  cancer  of,  mortality, 
no 

prognosis  of,  no 

results  of  operation,  no 


Alkalescence  of  blood  in  cancer,  130 

Alloplasia,  63 

Amino  acid  in  urine  of  cancer,  132 

Ammonia  nitrogen  in  cancer  urine,  131 

Amount  of  lymph  flow  daily,  124 

Amphipyrenin  in  cancer  cells,  81 

Ampulla  of  Vater,  cancer  of,  50 

Amsterdam,  cancer  in,  39 

Anabolism  and  cancer,  315 

Anaemia,  cancer,  144 

Analysis    of    radiation    treatment    of 

cancer,  270 
volumetric  of  urine,  147 
Anaphylaxis  and  cancer,  219 
Anaplasia,  63,  188 

Anaplastic  or  embryonal  growth,  127 
Andral,  leucocytosis  in  cancer,  129 
Angio-cholitis  proliferans  and  cancer, 

48 
Angio-sarcoma,  60 
Animals,  cancer  in,  14 
Antibodies    protecting    from    cancer, 

i43,  144 

Antitryptic  power  of  cancer  blood,  76 

Antwerp,  cancer  in,  39 

Anus,  cancer  of,  47 

Apoplexy  mortality,  and  that  of  cancer, 
165 

Appendix,  cancer  of,  47 

Appetite    satisfied    versus  taste  grati- 
fied, 203 

Argentina,  cancer  in,  38,  207 
meat  eating  in,  207 

Arterial  system  in  spread  of  cancer,  115 

Arterio-sclerosis,  183 

Ascitic  fluid,  carcinomatous,  74 

Asia,  cancer  in,  2 1 

Aspirin,  value  of,  in  cancer,  326 

Asylums,  cancer  in,  213 

Australasia,  cancer  in,  21 


439 


440 


1NM.X 


Australia,  cancer  in,  35 

increase  of  cancer  in,  208 
meat  eating  in,  208 
Autogenous  action  of  cells,  11 
Autolysate  of  tumors  for  cancer,  286 
Autolysin,  Beebe's,  for  cancer,  284 
Autolysis  in  cancer,  74,  78 
Autonomous  nature  of  tumors,  171 
Axilla,  cancer  of  the,  423 
Axillary  nodes  in  breast  cancer,  118 


B 


Bacterial  influence  in  cancer,  319 

injections  for  cancer,  272 
Baldness  and  cancer,  180 
Bard,  hemolytic  properties  in  cancer 

blood,  129 
Barker,     results     in     breast     cancer 

operations,  102 
Basal-cell  carcinoma,  42,  43 
Bashford,  cancer  in  India,  312 
Basic  factor  in  cancer,   the  systemic 

condition,  300 
Beebe,  protein  distribution  in  cancer, 

7i 
Beebe's  antolysin  for  cancer,  284 
Belgium,  cancer  in,  39 
Bell,  Robert,  character  of  the  cancer 

cell,  83 
constipation  and  cancer,  154 
constitutional    nature    of  cancer, 

163 
Benecke,  diet  in  cancer,  206 
Benign  tumors,  171 

removal  of,  followed  by  cancer, 

121 
Benratt,  cancer  in  India,  36,  312 
Bergman  and  Meyer,  antitryptic  power 

of  cancer  serum,  76 
Berkeley's  serum  for  cancer,  282 
Berlin,  cancer  in,  39 
Betel  chewing  and  cancer,  37 
Bevan,  cancer  of  the  rectum,  237 
Bierfreund,   regeneration  of  blood  in 

cancer,  129 
Bio-chemistry  of  cancer,  71 


Biological  problem,  cancer  is  a,  213 

treatment  of  cancer,  286 
Bio-therapy  of  cancer,  272 
Black  races  in  Egypt  free  from  cancer, 

227 
Bladder,  cancer  of  the,  363,  419,  421 
Blastomycctcs  and  cancer,  286 
Blindness  as  to  the  cause  and  cure  of 

cancer,  432 
Blood,  cancer,  antitryptic  power  of,  76 
cells,  red,  potassium  in,  323 
changes  in  cancer,  70 

under  proteal  treatment,  290 
character  of,  indicated  by  urine, 

i47 
diagnosis  in  cancer,  140 
in  cancer,  128,  139 
metastases  in  cancer,  122 
plasma  in  cancer,  141 
Bloodgood,     axillary    adenopathy    in 

breast  cancer,  102 
Blumenthal,  oxyproteic  acids  in  urine 
of  very  early  cancer,  150 
tryptic  digestion  and  cancer,  72, 

74 
Body  weight,  relation  of  urinary  solids 

to,  148 
Boggs,  radium  therapy  in  cancer,  256 
Bone  metastasis,  51,  54,  60 
Bowels,  complete  evacuation  of,  and 

cancer,  154,  326 
Bra,  myxomycetes  and  cancer,  280 
Braithwaite,  salt  and  cancer,  219 
Branchial  clefts  and  cancer,  187 
Brazil,  cancer  in,  38 
Breast,  cancer  of,   56,   232,  337-348, 
352,  376 
diagnosis  of,  98 
prognosis  of,  106 
Paget's  disease  of,  382 
primary  cancer  of,  337~344,  352 
Brieger    and   Trebing,    cancer   serum 

inhibiting  trypsin,  76 
British  Columbia,  cancer  in,  39 
Honduras,  cancer  in,  38 
West  Indies,  cancer  in,  39 
Brussels,  cancer  in,  39 


INDEX 


441 


Buccal  cavity,  cancer  in,  392,  397,  399 

cancer  of,  diagnosis  of,  89 
Bulkley,  cancer  in  New  York  City,  16 
personal  observations  on  cancer  in 
the  Far  East,  38 
Bumm    and    Warnekross,    #-ray    in 

cancer,  248 
Butlin,  cancer  of  the  tongue,  90 
Butter,  amount  to  be  consumed,  310 
Buyo  or  Philippine  cancer,  180 
Byrne,  cautery  in  uterine  cancer,  235 
results  in  uterine  cancer,  236 


Cancer, 
and 
and 
and 
and 

and 
and 
and 
and 
and 


and 


Cachexia  in  cancer,  100,  125,  133,  144, 

and 

146,  324 

and 

metabolism  in,  145 

Caffeine,  amount  in  coffee,  210 

Cahen,  removal  of  ovaries  for  cancer, 

and 

i57 

Cairo,  cancer  in,  35 

and 

Calcium,  relation  to  cancer,  155 

and 

Calculi,  vesical,  and  cancer,  52 

and 

Calories,  amount  required  for  cancer 

and 

patients,  308 

and 

Cameron,  radium  therapy  of  cancer, 

and 

259 

and 

Canada,  cancer  in,  39 

and 

Cancer,  absence  of,  in  wound  healing, 

and 

170 

and 

absent    from    negroes  in  slavery 

and 

times,  226 

and 

acidosis  in,  133,  145 

and 

age,  158,  192 

and 

anaemia,  144 

and  acidity  of  organs,  195 

and 

and  action  of  endocrinous  glands, 

and 

155,  iS9 

and 

and  alcohol,  211 

and 

and  anaphylaxis,  219 

and 

and  angio-cholitis,  48 

and 

and  branchial  clefts,  187 

and 

and  change  in  mode  of  life,  220 

and 

and  chronic  mastitis,  172 

and 

and  coffee,  210 

and 

and  colonic  absorption,  319 

and  constipation,  154 

cystitis,  53 

deranged  metabolism,  324 

embryology,  168,  187 

extract  of  endocrinous  glands, 

326 

evolution,  178 

hypernutrition,  324 

idleness,  40,  220 

immunity,  189 

imperfect  digestion,  153 

elimination,  154 

intestinal  excretion,  317 

urine,  320 
indolence,  179 
inflammation,  171 
internal  secretions,  155 
secretion  of  ovaries,  156 

of  testicles,  156 
irritation  from  food  and  drink, 
216 

keratoses,  172 
kidney  action,  320 
local  treatment,  327-331 
luxury,  220 
lymphatics,  117 
malignant  teratomata,  170 
mastication,  153 
meat  eating,  301 
medical  treatment,  315 
misplaced  sweat  glands,  187 
mutation  theory,  157 
nervous  conditions,  183,  314 
nutrition,  190 

occupied    and    unoccupied 
males,  220 
pituitary  gland,  156 
potassium,  321,  32? 
protein  consumption,  192 
psoriasis,  219 
radium,  251 
salt,  219 

stagnant  colon,  31S 
susceptibility,  189 
thymus  gland,  155 
thyroid  extract,  326 
gland,  156 


44  2 


INDEX 


Cancer,  and  tobacco,  218 
and  trauma,  197 
and  tuberculosis,  6,  15,  29,  40 
and  urbanization,  220 
and  vegetable  extract  soup,  309 
and  vesical  calculi,  52 
and  waning  of  sexual  powers,  157 
and  warts,  173 
and  well-to-do  persons,  220 
and  xanthin,  218 
as  a  disease,  carcinosis,  144 
Beebe's  autolysin  in,  2S4 
bio-chemistry  of,  71 
bio-therapy  of,  272,  286 
bones  affected  in,  60 
cachexia,  133,  134,  144,  146 
caused  by  nervous  conditions,  220 
cell,    desmoplastic    attribute    of, 

169 
chemical  extirpation  of,  386 
congenital  element  in,  183,  185 
cure    of,    depends     on    restored 

nutrition,  436 
daily  deaths  from  cancer  in  New 

York  City,  223 
deaths  in  United  States,  16,  222 

from,  in  various  states  of 

the  Union,  23 

in  relation  to  location  of 

lesion,  225 

in  United  States  by  age, 

226 
diagnosis  of,  86 
dietetic  treatment  of,  299 
early,  and  excellent  health,  323 
embryonic  rests  in,  138 
emulsions,  injection  for  cancer,  280 
en  cuirasse,  278,  279 
etiological  factors  in,  183 
experimental,   effect   of   diet   on, 

214,  215 
familial  element  in,  183,  194 
faulty  metabolism  in,  138 
hereditary  element  in,  183 
hygienic  treatment  of,  299 
immunity  of  certain  organs,  194 
in  fat  subjects,  152,  190 


Cancer,  in  Holland,  210 
in  Hungary,  210 
in  New  York  City,  23,  222 
in  prisons  and  asylums,  213 
in  relation  to  age,  224 

to  sex,  225 
in  Scandinavia,  217 
increase  in  England,  207 

in  New  Zealand,  207 

of  urobilin  in  urine,  150 
juice    injected    causing    lympho- 
cytosis, 143 
lesion    a    product    of    systemic 

derangement,  115 
local  factors  in,  196 

recurrence  of,  121 
logic  of  situation  regarding,  436 
lymphatics  in,  60 
malignancy  of,  126 
medical  aspects  of,  160 

treatment  of,  299 
results,  428 
metabolism  of,  137 
metastasis  in,  114 
mortality  and  race,  226 

from,  16,  22? 

increased    under    sur- 
gical treatment,  301 

low  in  Ireland,  208 

rising  in  Italy,  208 
multiple  primary,  103 
nosology  and  relations  of,  168 
of  alimentary  tract,  mortality,  no 
prognosis  of,  no 
results    of    operation,  no 
of  ampulla  of  Vater,  50 
of  anus,  47 
of  axilla,  423 
of  bladder,  363,  419,  421 
of  breast,  56,  232,  337-348,  352, 
376 

chemical  extirpation  of,  385 

diagnosis  of,  98 

duration  of,  106 

prognosis  of,  106 

results  of  operation,  106,  107 
of  buccal  cavity,  diagnosis  of,  89 


INDEX 


443 


Cancer  of  cervix  uteri,  55 
diagnosis  of,  96 
local  treatment  of,  330 
of  cheek,  diagnosis,  91 
of  corpus  uteri,  56 
of  ear,  402 
of  face,  403 

of  fundus  uteri,  diagnosis  of,  97 
of  gall  bladder,  49,  237 
diagnosis  of,  94 
duration  of,  112 
prognosis  of,  112 
of  hand,  423 
of  head  and  neck,  400 
of  hip  bone,  424 
of  intestine,  46,  405 

diagnosis  of,  93 
of  jaw,  398 

of  kidney,  51,  362,  419 
diagnosis  of,  94 
mortality  of,  112 
prognosis  of,  112 
of  larynx,  392,  400 
of  lip,  366,  392 
diagnosis  of,  89 

end  results  of  operations  on,  231 
prognosis  of,  108 
of  liver,  48,  405,  413 
diagnosis  of,  94 
prognosis  of,  no 
of  male  breast,  376,  388 
of  mouth,  392,  397,  399 
diagnosis  of,  89,  91 
mortality  of,  109 
prognosis  of,  109 
results  of  operation,  109 
thermo-therapy  in,  257 
of  nose,  401 
of  oesophagus,  239,  405 

diagnosis  of,  92 
of  other  localities,  423 
of  palate,  diagnosis  of,  91 
of  pancreas,  47 

diagnosis  of,  93 
of  penis,  423,  425 
of  prostate,  53,  361,  419 
diagnosis  of,  95 


Cancer  of  rectum,  47,  237,  360,  417 

mortality  of,  no 

prognosis  of,  no 
of  soft  palate,  392 
of  stomach,  44,  237,  360,  405,  407, 

4i3 
and     liver,     deaths     from,    in 

United  States,  225 
diagnosis  of,  92 
mortality  of,  no 
prognosis  of,  no 
results  of  operation,  no 
of  supra-renal,  420 
of  thigh,  424 
of  tongue,  364,  392,  393 
diagnosis  of,  90 
prognosis  of,  109 
of  tonsil,  365,  400 
diagnosis  of,  91 
of  urinary  bladder,  52 
diagnosis  of,  95 
prognosis  of,  112 
of  uterus,  55,  348-350,  389 
deaths  from,  in  United  States, 

225 
diagnosis  of,  95 
prognosis  of,  108 
results  of  operation,  108,  235 
of  uvula,  diagnosis  of,  91 
or  carcinosis  as  a  disease,  144 
patients,  directions  for,  304 
phobia,  370 
problem,  the  real,  301 
prophylaxis  of,  299 
proteal  treatment  of,  289 
protomorphic    theory   of   cancer, 

289 
racial  immunity  in,  191 
susceptibility  to,  191 
radium  in  treatment  of,  242 
rarity  of,  in  Far  East,  214 
in  religious  orders,  213 
on  the  extremities,  166 
recurrence  of,  114 
relation  of  calcium  to,  155 
of  diet  to,  201 
to  adenoma,  169 


444 


INDEX 


Cancer,     relation     to    constitutional 

diseases,  177 
saliva  acid  in,  152,  21S 
sero-therapy  of,  of  doubtful  value, 

434 
special  immunity  in,  191 
spread    through   arterial    system, 

"5 

lymphatic  system,  115 

venous  system,  115 
surgery  of,  statistics,  222,  228 
susceptibility  of  certain  organs  to, 

194 
systemic     condition     real     basic 

factor  in,  300 
terminal  result  of  intestinal  stasis, 

154 

toxin,  therapy  of,  273 

trophoblastic,  hypothesis  of,  186 

urine  in,  146 

vaccino-therapy  of,  273 

.v-ray  and  radium  in,  242 
Cancroide,  diagnosis  of,  89 
Cancroidin,  Schmidt's,  for  cancer,  286 
Canities,  180 

Carbon,  percentage  in  body,  202 
Carcinoma,  370 

and  chronic  irritation,  1 74 

difference  from  sarcoma,  173 

stroma  of,  173 
Carcinosis  as  a  disease,  144 

cachexia  of,  125 

duration  of,  88 
Caries,  dental,  177 
Cases  of  neoplastic  diseases,  369 
Catabolism  and  cancer,  315 
Caution  in  using  thorium  paste,  375 

nitrate  of  silver,  372 
Cecum,  cancer  of,  47 
Centrosome,  changing  in  cancer,  5 
Cereals,  proteids  in,  209 
Cervix  uteri,  cancer  of,  55 
diagnosis  of,  96 
local  treatment,  330,  349,  390 
Change  in  mode  of  life  and  cancer, 

220 
Cheek,  cancer  of,  diagnosis,  91 


Chemical  composition  of  cancer  cell 
77 
excitants  of  cancer  lesions,  198 
extirpation  of  cancer,  386 

Chemistry  of  cancer  cell,  71 
of  nutrition,  201 

Chemo-therapy,  histogenic,  for  cancer, 
286 

Chimney  sweeps'  cancer,  196 

China,  cancer  in,  37 

Chittenden,  principles  of  diet,  205 

Chlorides  diminished  in  cancer  urine, 

151 
Cholesterol  and  cancer,  143 
Chololithiasis  and  cancer,  49 
Chondro-sarcoma,  61 
Chorio-epithelioma,  122,  143,  168,  175, 

186 
Chromatin  in  cancer  cells,  82 
Chromosomes  in  cancer  cells,  65 
Chronic  irritation  and  carcinoma,  174 
Cities,  cancer  in,  21,  22,  28 

of   the    Union,   death   rate   from 

cancer  in,  223,  224 
Civilization  and  cancer,  28,  184 

effect  on  food,  203 
Clark,  John,  radium  therapy  in  cancer, 

252 
Clark,    Wm.   L.,    radium   therapy   in 

cancer,  253 
Clarke  and  Keene,  radium  therapy  in 

cancer,  253 
Clinical  considerations  and  results,  334 

study  of  cancer,  2 
Clothing  and  cancer,  32 
Coca,  vaccino-therapy  for  cancer,  277 
Coffee  and  cancer,  210 

consumption  of,  in  United  States, 

210 
Cofferdam  formed  in  cancer,  68 
Cohnheim,  embryonic  rests,  4 
Cohnreich,   changes  of  the  blood  in 

cancer,  140 
Coley's  serum  for  sarcoma,  274 
Colon,  cancer  of,  46 

stagnant  and  cancer,  318 
Colored  race,  rarity  of  cancer  in,  25 


INDEX 


445 


Combined  treatment  of  cancer,  437 
Complete    evacuation    of    bowels   in 

cancer,  154,  318 
Composition  of  human  body,  201,  202 

of  tumor  cells,  81 
Conclusions,  431 

Confidence  of  patient  to  be  secured,  316 
Congenital  cancer,  183,  185 
Connective  tissue  in  cancer,  68 

in  sarcoma,  61 
Constipation  and  cancer,  154,  318 

universal  in  cancer,  318 
Constitutional    diseases,    relations    of 

cancer  to,  177 
nature  of  cancer,  135 
Contagiousness  of  cancer,  2 
Convalescent     serum,    injection     for 

cancer,  278 
Cooking,  errors  in,  216 
Cooper,     Sir     Astley,    constitutional 
nature  of  cancer,  102 

permanence  of,  240 
Corns  and  cancer,  173 
Corpus  uteri,  cancer  of,  56 
Creoles  in  Africa,  rarity  of  cancer  in, 

227 
Crile,  cancer  of  the  rectum,  237 
Criticism  as  to  diagnosis,  336 
Cure  of  cancer  depends  upon  restored 
nutrition,  436 

permance  of,  240 
Curetting    in  cutaneous  epithelioma, 

373 
Cutaneous  epithelioma,  42 

excluded  from  study,  372 
Cylindroma,  170 
Cystitis  and  cancer,  53 
Cytolytic  serum  for  cancer,  272,  280 

D 

Deaths  from  breast  cancer,  377 

daily  from  cancer  in  New  York 

City,  223 
from  cancer,  increase  in  New  York 
City,  222,  223 
in  United  States,  222 
by  age,  226 


Deaver,  results  of  operations  on  breast 

cancer,  234 
De    Bloeme,     nitrogen     partition    in 

cancer  urine,  150 
Defensive  ferments  in  cancer,  143 
Degres,  imperfect    nitrogen   disinteg- 
ration in  cancer  urine,  151 
Dental  caries,  177 

Desmoplastic  attribute  of  cancer  cell, 
169 
secretion,  68 
Details  in  the  medical  treatment  of 

cancer,  316 
Development  and  normal  growth,  168 
Diagnosis  from  blood  in  cancer,  140 
influencing  statistics,  17 
of  cancer,  86 
Diathermy  in  oral  cancer,  257 
Diathesis,  neoplastic,  190 
Diet  card  for  cancer,  304-308 

effect  on  experimental  cancer,  214 
mineral  elements  in,  215 
relation  to  cancer,  201 
Chittend's  principles  of,  205 
Voit's  principles  of,  204 
Dietary  regulation  in  cancer,  301 
Dietetic  treatment  of  cancer,  difficul- 
ties in  carrying  out,  303 
of  cancer,  299 
duration  of,  302 
Difficulties   in   carrying    out   dietetic 

treatment  of  cancer,  303 
Digestion,  effect  of  tea  on,  211 
imperfect,  and  cancer,  153 
influence  of  cancer  on,  130 
intestinal,  in  cancer,  131 
Dimpling  of  skin  in  cancer  of  breast, 

99 
Directions  for  cancer  patients,  304-308 
Douche,  vaginal  in  uterine  cancer,  330 
Doyen,    micrococcus  neoformans  and 

cancer,  287 
Duct  carcinoma  of  breast,  58 
Ductless  glands  and  nutrition,  295 

hypofunction    of,   and    cancer, 

i59 
Duodenum,  cancer  of,  46 


446 


INDEX 


Duration    of    dietetic    treatment    of 
cancer,  302 
of  observation  affecting  statistics, 
229 
Dysplasia,  63 


Ear,  cancer  of,  402 

Early  cancer,  134 

life,  why  cancer  absent  in,  82-85 

Egypt,  cancer  rare  in,  227 

Einhorn,  Kahn,  and  Rosenblum,  nitro- 
gen partition  in  cancer  urine, 
150 

Elsberg,  hemolytic  properties  of  cancer 
blood,  129 

Emaciation  in  tumor  growths,  128 

Embryology  and  cancer,  168 

Embryolytic  injections  for  cancer,  281 

Embryonal  cells  in  sarcoma,  61 
or  anaplastic  growth,  127 

Embryonic  development  and  cancer, 
187 
rests,  of  Cohnheim,  4,  138 

Emulsions,  cancer,  injection  for  cancer, 
280 

Encephaloid  cancer,  101 

End    results    of    mouth   cancer,   392, 

397 
Endocrinous  glands  and  cancer,   155, 

159,  191 
and  nutrition,  295 
extracts  in  cancer,  326 

value  of  still  undecided,  435 
England,  cancer  in,  16 
increase  in,  207 
meat  eating  in,  207 
Engleman  on  untreated  cancer,  236 
Enzymes  in  cancer  cells,  79 
Epiblast,  carcinoma  developing  from, 

174 
Epidermoid,  carcinoma,  diagnosis,  89 
Epithelial  cancer,  diagnosis  of,  89 

pearls,  43 
Epithelioma  basocellare,  42 

cutaneous,  *-ray  in,  245 


Epithelioma  of  the  skin,  370 
diagnosis  of,  89 
excluded  from  real  cancer,  372 
treatment  of,  373 
spinocellare,  42 
Epithelium,  normal  and  pathological 

relations,  169 
Equilibrium  in  nutrition,  204 
Erlich,  effect  of  diet  on  experimental 

cancer,  214 
Errors  in  cooking  food,  216 

of  diet  causing  disease,  201 
Eskimos,  cancer  among,  39,  192 
Esmarch,  diet  in  cancer,  206 
Etiological  factors  in  cancer,  183 
European  countries,  cancer  in,  20 
Evolution  and  cancer,  178 
Ewing,  cancer-genetic  cells,  n 
definition  of  carcinoma,  8 
histo-pathology  of  cancer,  42 
radium  treatment  of  cancer,  258 
treatment  of  cancer  on  biological 
principles,  273 
Excretion,    imperfect    intestinal,    and 

cancer,  317 
Experience   in   medical   treatment  of 

cancer,  335 
Experimental  cancer,  effect  of  diet  on, 

214,  215 
Extirpation,  chemical,  of  cancer,  386 
Extremities,  rarity  of  cancer  on,  166 


Face,  cancer  of,  403 

Failla,     physical     considerations     of 

radium,  251 
Falci,  lactic  acid  in  tumors,  72 
Family  cancer,  183,  184,  194 
Far  advanced  cancer  of  the  breast, 

34i,  347,  355,  383 
East,  rarity  of  cancer  in,  37,  38, 

214,  311 
Fat,   bodily,   relation    to   cancer,    73, 

190 
Ferments  in  tumors,  73 
Fiji  Islands,  cancer  in,  34 


INDEX 


447 


Fischera,  biological  treatment  of  can- 
cer, 286,  287 

Fletcher,  mastication  and  insalivation, 
152 

Food  and  cancer,  31 

errors  in  cooking,  216 

Foods,  protein,  digestion  of,  205 

Fox,  F.  J.,  Wassermann  reaction  in 
cancer,  75 

France,  cancer  in,  39 

Fredrich,  statistics  of  uterine  cancer, 
236 

Free  bowel  evacuation  and  cancer,  154 

Frequency  of  cancer,  14 

Freund  and   Kaminer,  normal  serum 
injection  in  cancer,  279 

Friedenwald,  results  in  cancer  of  the 
stomach,  in,  237 

Fundus  uteri,  cancer  of,  diagnosis  of,  97 


Gall  bladder,  cancer  of  the,  49,  237 

diagnosis  of,  94 

prognosis  of,  in 
stones  and  cancer,  49 
Gastric  cancer,  44,  360,  405,  407,  413 
Geographical   distribution   of   cancer, 

14 
German  advances  in  #-ray  therapy, 

249 
Germany,  cancer  in,  39 
Giant  cell  sarcoma,  61,  62 
Glamor  of  surgery  obscuring  medical 

consideration,  164,  299 
Glands,  endocrinous,  and  cancer,  155, 

i59 
Glio-sarcoma,  61 
Glutamic  acid  in  cancer  cells,  72 
Granuloma  ta,  172 
Greeks,  cancer  in,  38 
Green  card  diet  slip  for  cancer,  304- 

308 
Gross,    distant   metastasis    in    breast 

cancer,  119 
parts  affected  by  metastases,  60 
Gruner,  changes  of  the  blood  in  cancer, 

140 


II 


Habits  of  life  and  cancer,  33 
Haematuria  in  kidney  cancer,  94 
Haemoglobin  in  cancer,  142 
Hemolytic  properties  of  cancer  blood, 

129 
Haig,  uric  acid  element  in  cancer,  217 
Halsted,  operations  in  breast  cancer, 

102 
Hand,  cancer  of  the,  423 
Handley,  duration  of  life  in  untreated 

cancer,  106 
permeation  theory  in  cancer,  59, 

116, 120 
Handling,   rough,   of  tumors  causing 

metastasis,  115 
Hartwell,    results    of    operations    in 

breast  cancer,  234 
Haser,  estimation  of  solids  in  urine, 

149 
Head,  cancer  of  the,  400 
Health  excellent  in  beginning  cancer, 

323 
Heart-disease    mortality  and  that  of 

cancer,  165 
Hereditary  element  in  cancer,  3,  183 
Hertzler,  cancer  of  the  lip,  231 
Heteroplasia,  63 
Heterotopia,  63,  186 
Heterotopic  theory  of  cancer,  187 
Heurtaux,    results    of    operation    on 

breast  cancer,  233 
Hildebrand,  cancer  of  the  breast,  232 
Hip  bone,  cancer  of  the,  424 
Hislop  and  Fenwick,  cancer  in  New 

Zealand,  34 
Histogenic   chemotherapy   of   cancer, 

286 
Histo-pathology  of  cancer,  42 
Hodenpyl,  serum  injections  in  cancer, 

278 
Hodgkin's  disease,  Coley's  serum  in, 

276 
Hoffman,  statistics  of  cancer,  16,  18, 

20 
Holland,  cancer  and  coffee  in,  39,  210 


448 


INDEX 


Hormone  of  cancer  cells,  5,  296 
Hornifying  cancroid,  4a 
Horowitz'  poultice  for  cancer,  284 
Hungary,  cancer  in,  210 

smallest  consumer  of  coffee,  210 
Hunter,  John,  constitutional  nature  of 

cancer,  138 
Hutchinson,  caffeine  in  coffee,  210 
Hydrogen,  percentage  in  body,  202 
Hygienic  adjustment  in  cancer,   301, 

treatment  of  cancer,  299 
Hypernutrition  and  cancer,  324 
Hypoblast,    cancer    developing    from, 

i74 
Hypofunction  of  ductless  glands  and 

cancer,  159 


Iceland,  cancer  in,  39 
Idleness  and  cancer,  40,  220 
Immunity  and  cancer,  189 
from  cancer,  30 

of  certain  organs  to  cancer,  194 
Immunization,    active,    dangerous    in 

cancer,  287 
Imperfect   intestinal   elimination   and 

cancer,  154,  317 
Imperial  Cancer  Research  Fund,  212 
Impotence  of  surgery  in  cancer,  236, 

237,  430 
Impotence  of  surgery  in  mouth  cancer, 

393.  397 
Inaccessible  regions  and  diagnosis,  18 
Increase  of  cancer,  16-19 

deaths  in  United  States,  222 

in  cities,  21 
Index  Medicus,  Nosology  of  Cancer,  13 
India,  rarity  of  cancer  in,  36,  311 
Indians,  cancer  in,  26 
Indican  in  cancer  urine,  132 
Indolence  and  cancer,  179 
Infiltration  of  cancer,  67 
Inflammation  and  cancer,  171 
Influence  of  cancer  on  digestion,  130 
Inheritance  of  cancer,  184 


Inhibiting  substances,  cell  growth,  199 
Inoculation  of  cancer  tissue,  75 
Inorganic  material  of  cancer  cells,  78 
Insalivation,    perfect,    important    in 

cancer,  153,  309 
Instinct,  animals  guided  by,  201 
Intelligence  of  cells,  12 
Internal  secretions  and  cancer,  155 
Intestinal  elimination  and  cancer,  131, 

154 
Intestine,  cancer  of,  46,  405 

diagnosis  of,  93 
Intoxication  from  tumor  growth,  126 
Intrapleural  invasion  by  cancer,  120 
Ireland,  low  cancer  mortality  in,  208 

meat  eating  in,  207 
Iron  and  cancer,  325 

percentage  in  body,  202 
Irritation,  chronic  and  carcinoma,  174, 

216 
Italy,  cancer  in,  39 

meat  eating  in,  20S 


Jacob's  ulcer,  diagnosis  of,  89 
Jacoby,  autolytic  ferments  in  cancer 

tissue,  74 
Jamaica,  cancer  in,  39 
Janeway,  general  study  in  the  use  of 

radium,  268 
radium  in  cancer  of  the  lip,  268 

tongue,  269 

uterus,  268 
Japan,  cancer  in,  37 
Jaundice  with  cancer,  93,  94 
Jaw,  cancer  of  the,  398 
Jews,  cancer  in,  25 
Johnson,  absence  of  cancer  in  Africa, 

36,  227 
Jones,  Price,  changes  of  the  blood  in 

cancer,  140 
Judd,  Mayo,  cancer  of  the  breast,  233 


Kangri  burn,  37 
Kariokinesis,  10,  65 


INDEX 


449 


Kataplasia,  63 

Kellogg,   absence  of  cancer  in   vege- 
tarians, 209 
Kelly,    Howard,    radium    therapy    in 

cancer,  252 
Keratoses  and  cancer,  172 
Kessler,  diet  in  cancer,  215 
Kidney  action  and  cancer,  142,  320 
cancer  of,  51,,  362,  419 
diagnosis  of,  94 
mortality  of,  112,  165 
prognosis  of,  112 
secretion  indicating  character  of 
the  blood,  147 
Kioto,  cancer  in,  37 
Klein,  statistics  of  uterine  cancer,  236 
Klemperer,  reduced  carbonic  acid  in 

cancer  blood,  130 
Koch,  tissue  thrombin  and  cancer,  288 
Kullman,     hemolytic     properties     of 

cancer  blood,  129 
Kuster,    axillary    invasion    in    breast 
cancer,  118 


Lacteals,  function  of,  124,  125 
Lactic  acid  in  stomach  in  cancer,  130 

in  cancer  cells,  72 
Lambe,  diet  in  cancer,  162 
Lane,  Sir  Arbuthnot,  intestinal  stasis 

and  cancer,  154 
Langerhan's  islands  affected  in  cancer, 

48 
Larynx,  cancer  of  the,  392 
Latham,  cancer  in  the  well-to-do,  40 
Lecithin  and  cancer,  73 
Leucocytosis  in  cancer,  129 
Leucoplakia  and  cancer,  172 
Levin,  results  of  operations  on  breast 

cancer,  233 
and  Joseph,  #-ray  in  cancer,  246 
mechanism  and  action  of  radium 

on  tumor  tissue,  261 
Lewin,   antitryptic  power    of    cancer 

serum,  76 
Life  conditions  influencing  cancer,  25 

29 


Lilienthal,    endorsing    Coley's  serum, 

27S 
Linin  in  cancer  cells,  81 
Lip,  cancer  of,  366 

diagnosis  of,  89 
end  results  of  operations,  231 
prognosis  of,  108 
Lipo-sarcoma,  61 
Little,    disordered    nutrition    causing 

cancer,  159 
Liver,  cancer  of,  48,  405,  413 
diagnosis  of,  94 
prognosis  of,  no 
deranged  in  cancer,  T38 
Lobular  epithelioma,  43 
Local  factors  in  cancer,  196 

nature  of  cancer  untenable,  135 
recurrence  of  cancer,  121 
treatment  of  cancer,  327-331 
Location  of  lesion  in  relation  to  cancer 

deaths,  225 
Logic  of  situation  regarding  cancer,  436 
Loose,  £-ray  in  cancer,  248 
Lorand  on  retained  bowel  excretion, 

319 
Loss  of  nutriment  in  cooking  potatoes, 

215 
Lott,  removal  of  ovaries  for  cancer,  157 
Louis,  diminished  blood  in  cancer,  129 
Lubhardy,  cancer  of  the  breast,  233 
Lure  of  surgery,  368 
Luxury  and  cancer,  220 
Lymph  flow,  amount  of,  124 

node  metastasis  in  cancer,  122 
nodes  and  cancer,  117 
in  breast  cancer,  117 
in  stomach  cancer,  118 
in  tongue  cancer,  117 
in  uterine  cancer,  118 
Lymphatic  system,  functions  of,  115 
in  spread  of  cancer,  115 
protecting  from  cancer,  116 
Lymphatics  in  cancer,  60,  116 
in  sarcoma,  62 
influence  of,  in  cancer,  142 
of  stomach,  45 
Lymphoma  and  sarcoma,  174 


450 


INDEX 


Lymphosarcoma,  61 
Coley's  serum  in, 

M 


76 


Mackay,  cancer  en  cuirasse,  278 
Madden,  cancer  in  Africa,  35 
Male  breast,  cancer  of  the,  376,  388 
Malignancy  of  cancer,  126 
Malignant  teratomata  and  cancer,  176 
Manilla,  cancer  in,  37 
Maragliano,   hemolytic   properties  of 

cancer  blood,  129 
Marsden's  paste  in  epithelioma,  373 
Mastication  and  cancer,  153 

perfect,  important  in  cancer,  309 
Mastitis,  chronic,  and  cancer,  172 
Mayo,  acidity  and  cancer,  153,  217 
cancer  and  civilization,  160,  161 
of  rectum,  238 
of  stomach,  237 
production  of  acid  in  cancer,  145 
prophylaxis  of  cancer,  160 
Mayo  clinic,  cholesterol  and  cancer, 
143 
gall  stones  and  cancer,  49 
McCann  on  errors  in  cooking,  216 
McGregor,    Sir    Wm.,    cancer  among 
Melanesians,  34 
vegetarianism  and  cancer,  227 
Meat  eating  and  cancer,  206,  301 
in  Argentine  Republic,  207 
in  Australia,  208 
in  England,  207 
in  Ireland,  207 
in  Italy,  208 
in  Spain,  208 
in  United  States,  207 
Medical  aspects  of  cancer,  160 
treatment  after  operations  on 
cancer,  87,  162 
of  cancer,  299,  301,  315 
results,  428 

from,  334,  428 
of  earljr  cancer,  87 
Melanesians  exempt  from  cancer,  34, 
227 


Melano  sarcoma,  426 

Melanotic  sarcoma,  Coley's  serum  in, 

276 
Memorial  Hospital,  recent  report  on 
radium,  265 
#-ray  therapy  in,  251 
Mental  states  and  cancer,  314 
Mesoblast  producing  sarcoma,  174 
Mesoblastic  tumor,  sarcoma  a  cancer- 
ous form  of,  427 
Metabolism  and  cancer,  9 

deranged,  and  cancer,  138,  324 
of  cancer,  137 

cell,  77 
proteid,  in  cancer,  150 
Metaplasia,  63,  188 
Metastases  checked  by  x-ray,  123,  246 
of  bones,  51,  54 
of  cancer,  114 
production  of,  123 
Methods  of  application  of  radium,  266 
Mexico,  cancer  in,  38 
Meyer,  Willy,  results  of  operations  on 

breast  cancer,  234 
Micrococcus  neoformans  and  cancer, 

287 
Mineral  elements  in  diet,  215 

starvation  and  cancer,  215 
Misbehavior  of  cancer  cells,  64 
Mitotic  changes  in  cancer  cells,  65 
Mohammedans,  cancer  in,  38 
Moore,    Cuneo,   and   Colwell,   lymph 
invasion  in  stomach  cancer, 
118 
Morphine  harmful  in  cancer,  314 

not     necessary     with     thorough 
medical  treatment,  314,  419 
Mortality  from  cancer,  222 

treated  medically,  428 
Mouth,  cancer  in,  392,  397,  399 
diagnosis  cf,  89,  91 
prognosis  of,  109 
radium  in,  no 
thermo-therapy  in,  257 
results  of  operation,  109 
Mucor  racemosus  injections  for  cancer, 
286 


INDEX 


451 


Muller,  albuminuria  in  cancer,  133 
Multiple  primary  cancer,  103 
Multiplication  of  cancer  cells,  64 
Munde,  results  in  uterine  cancer,  236 
Murphy,    John    B.,    cancer    in    fat 

subjects,  152 

cancer  of  the  breast,  232 
"cofferdam"  formation  in  cancer, 

68 
Mutation  theory  and  cancer,  157,  188 
Myeloma,  172 
Myo-sarcoma,  61 
Myxo-sarcoma,  61 


N 


Nature  of  cancer,  1 
Near  East,  cancer  in,  38 
Neck,  cancer  of,  400,  404 
Negative    results    of    laboratory    re- 
search, 2,  137 
Negroes  free  from  cancer  in  slavery 

times,  25,  226 
Nematode  worms  inciting  cancer,  198 
Neoplastic  diatheses,  190 

diseases,  cases  of,  369 
Nervous  conditions  and  cancer,   183, 

220,  314 
Neurotic  influences  and  cancer,  31 
New  York  city,  increase  of  cancer  in, 

23,  222 
New  York  Skin  and  Cancer  Hospital 

diet  card,  304 
New  Zealand,  cancer  in,  34 

meat  eating  in,  207 
Nicaragua,  cancer  in,  38 
Nitrate  of  silver,  danger  in  using,  372 
Nitrogen,  share  of,  in  the  system,  206 

in  cancer  cells,  78 

percentage  in  body,  202 

Nodes,  lymph,  in  cancer,  117,  122 

Noli  me  tangere,  diagnosis  of,  89 

Normal  and  pathological  relations  of 

epithelium,  169 

cells  and  cancer,  4,  13 

growth  and  development,  168 

serum  injections  in  cancer,  279 


Nose,  cancer  of,  401 

Nosology  and  relations  of  cancer,  168 

Nuclear  fluid  in  cancer  cells,  81 

Nuclein,  importance  of  in  body,  81 

Nucleohiston,  71 

Nutriment,  loss  of  in  cooking,  215 

Nutrition  and  cancer,  189 

chemistry  of,  201 

restored,  the  cure  of  cancer,  436 
Nuts,  proteids  in,  209 


0 


Obesity  and  cancer,  134,  152 
Objections  to  statistics,  17,  27 
Occult  blood  in  cancer,  93 
Occupation  and  cancer,  3,  32 
Occupied  and  unoccupied  males  and 

cancer,  220 
(Esophagus,  cancer  of  the,  239,  405 

diagnosis  of,  92 
Oldekop,  diet  in  cancer,  206 

duration    of    life    in    untreated 

cancer,  106 
Oncotropic  substances,  197 
Ontario,  cancer  in,  39 
Operations  on  cancer,  ultimate  results 

of,  239 
Operative  interference,   results  of,  in 

cancer,  228 
Operator,  skill  of,  affecting  statistics, 

229 
Optimism   of   reporter   affecting   sta- 
tistics, 230 
required  in  medical  treatment  of 

cancer,  316 
Organo-therapy  for  cancer,  273,  295 
in  cancer,  value  still  undecided, 

434 
Osteo-sarcoma,  61 
Other  localities,  cancer  of,  422 
Ovaries,    internal    secretion    of    and 

cancer,  156 
Over-nourished  cells,  69 
Oxygen  in  cancer,  313 

percentage  in  body,  202 
Oxyproteids  in  cancer  urine,  150 


452 


INDEX 


Packard,   mineral    elements    in    diet, 

215 

Paget,  Sir  James,  duration  of  life  in 
cancer,  106 
constitutional   nature   of   cancer, 
162 
Paget's  disease  of  the  breast,  59,  382 
Palate,  cancer  of,  diagnosis  of,  91 
Pancreas,  cancer  of,  47 
diagnosis  of,  93 
Papillomata  and  cancer,  53,  169 
Paranuclein,  81 
Paris,  cancer  in,  39 
Parker,    Dr.    Willard,    constitutional 

nature  of  cancer,  163 
Pathology  of  cancer,  42 
Patience    required    in  medical  treat- 
ment of  cancer,  316,  331 
Penis,  cancer  of  the,  423,  425 
Pentose,  increased  in  cancer  cells,  72 
Perfect  mastication  and  cancer,  153 
Peritoneal  invasion  by  cancer,  120 
Permanency  of  cure  of  cancer,  240 
Perseverance  required  in  medical  treat- 
ment of  cancer,  316,  331 
Persistence,  indefinite,  in  dietary  treat- 
ment of  cancer,  303 
Personal  experience  as  to  vegetarian- 
ism and  cancer,  311 
Petry,  protein  distribution  in  cancer, 

7i 
Pfahler,  .r-ray  in  cancer,  247 
Philippine  cancer,  buyo,  180 
Philippine  Islands,  cancer  in,  37 
Phosphates  diminished  in  cancer  urine, 

iSi 
of  value  in  cancer,  325 
Phosphorus,  percentage  in  body,  202 
Pig  skin  appearance  in  breast  cancer, 

99 
Piles  and  cancer,  93 
Pituitary  gland  and  cancer,  156 
Plasma  of  blood  in  cancer,  141 
Plastin  in  cancer  cells,  81 
Poikilocytosis  in  cancer,  140 


Polk,  hemolytic  properties  of  cancer 
blood,  129 
recurrence  of  cancer,  236 
Polynesians  exempt  from  cancer,  34, 

227 
Polypi  and  cancer,  53 
of  intestine,  46 
of  rectum,  47 
Positive  results  of  laboratory  research,  4 
Post-operative  cancer  of  the  breast, 
339-341,  345,  356,  381,  385 
sarcoma,  350 
Potassium  and  cancer,  321,  322 
Potatoes,  loss  of  nutriment  in  cooking, 

21S 
Potential  malignancy  of  tumors,  128 
Prickle  cells,  43 
Primary  cancer  of  the  breast,  337-344 

of  liver,  48 
Principles  of  diet  Chittenden,  205 

Voit,  204 
Prisons,  rarity  of  cancer  in,  213 
Product    of    systemic    derangement, 

cancer  lesions  are,  115 
Production  of  metastases,  123 
Prognosis  of  cancer,  105 
Properties  of  the  cancer  cell,  63 
Prophylaxis  of  cancer,  299 
Prostate,  cancer  of,  53,  361,  419 

diagnosis  of,  95 
Proteal  treatment  of  cancer,  289,  297 
Proteid  foods,  digestion  of,  205 

metabolism  in  cancer,  150 
Proteids  in  cereals,  209 

in  nuts,  209 

in  vegetables,  209 
Protein,  animal,  faulty  partition  of,  in 
cancer,  302 

consumption  and  cancer,  192 
Proteins  of  cancer  cells,  71,  291 
Proteomorphic  theory  in  cancer,   289 
Psoriasis  and  cancer,  219 
Putrefaction  products  in  cancer  urine, 

132 
Pyknosis  of  nuclei  in  cancer,  81 
Pylorus,  cancer  of,  44,  45 
Pyorrhoea  alveolaris,  178 


INDEX 


453 


Quantity  of  blood  in  cancer,  129 
Quevli,  Nels,  cell  intelligence,  13 

R 

Racasen,   radium  therapy  in  cancer, 

254 
Race,  and  mortality  from  cancer,  226 
Racial  cancer,  184 

immunity  in  cancer,  191 
susceptibility  to  cancer,  191 
Radium  in  cancer,  242,  251 

in  cutaneous  epithelioma,  374 
Institute  of  London,  radium  the- 
rapy in,  255 
Ransohoff 's  test  in  cancer,  76 
Rarity  of  cancer  in  Far  East,  214 
in  prisons  and  asylums,  213 
in  religious  orders,  213 
on  the  extremities,  166 
Raw  vegetable  products  in  cancer,  311 
Real  cancer,  372 

problem,  301 
Recreation  and  cancer,  314 
Rectum,  cancer  of,  46,  47,  237,  360 
diagnosis  of,  93 
prognosis  of,  no 
Recurrence  of  cancer,  114,  236 
Regeneration  of  blood  in  cancer,  129 
Reid,  amino-acid  in  cancer  urine,  150 
Relation  of  diet  to  cancer,  201 
Relations  and  nosology  of  cancer,  168 
of   cancer  to   constitutional  dis- 
eases, 177 
Religious  orders,  rarity  of  cancer  in, 

213 
Renner,  cancer  in  Africa,  36 

rarity  of  cancer  in  Creoles,  227 
Reproduction  and  cancer,  53 
Restored  nutrition  the  cure  of  cancer, 

436 
Results  in  cancer  of  the  uterus,  389 
of  chemical  extirpation  of  breast 

cancer,  386,  387 
of  medical  treatment  of  cancer, 
334,  428 


Ribbert,  beginning  of  cancer  of  breast, 

57 
Richter,  absence  of  hydrochloric  acid 

in  gastric  cancer,  130 
Rio  Janiero,  cancer  in,  38 
Roberts,  effect  of  tea  on  digestion,  21 
Robin,  relation  of  chlorine  and  nitro- 
gen in  cancer  urine,  151 
Robinson,  salt  and  cancer,  220 
Rodent  ulcer,  diagnosis  of,  89 
Rome,  cancer  in,  39 
Ross,  cancer  in  Iceland,  39 

Forbes,   constitutional  nature  of 

cancer,  163 
on    relation    of    potassium    to 

cancer,  321 
thymus  gland  and  cancer,  155 
Ross  Hugh  Campbell,  changes  of  the 

blood  in  cancer,  139 
Ross,  H.  R.,  induced  cell-reproduction 

and  cancer,  84 
Rough    handling    of    tumors    causing 

metastasis,  115 
Round-cell  sarcoma,  61,  62 
Rouse,  effect  of  diet  on  experimental 

cancer,  215 
Rumpf,    diminished     alkalescence    in 

cancer  blood,  130 
Rural  districts,  cancer  in,  23 
Russell,  cancer  in  prisons  and  asylums, 

213 


Saliva  acid  in  cancer,  152,  217 

importance  of,  in  cancer,  152 
Salkowski,  colloidal  nitrogen  in  cancer, 

132 
Salt  and  cancer,  219,  220 
Samuels,   radium  therapy  in  cancer, 

253 
Sandwith,  cancer  in  India,  312 
Sarcoma,  60,  371,  426 

a  cancerous  form  of  mesoblastic 

tumor,  174,  426 
Coley's  serum  in,  2  74 
difference  from  carcinoma,  173 


454 


INDEX 


Sarcoma,  local  treatment  of,  331 

melanotic,  Coley's  serum  in,  276 

post-operative,  350 

stroma  of,  173 
Savage    tribes    practically    free    from 

cancer,  215 
Saxl,  increased  protein  derivatives  in 

cancer  urine,  132 
Scandanavia,  cancer  in,  217 
Schmidt,     recurrence     after     radium 

treatment,  257 
Schmidt's  cancroidin  in  cancer,  286 
Scirrhus  cancer,  69 

carcinoma  of  stomach,  45 
Sclerogenic  action  of  radiation,  264 

tissue,  68 
Secondary  cancer  of  liver,  49 
Secretions,  internal,  and  cancer,  155 
Segmentation  of  cancer  cells,  64 
Sero-therapy    of    doubtful    value    in 

cancer,  434 
Serous  cavities  invaded  by  cancer,  119 

injections  for  cancer,  272 
Serum,  Berkeley's  for  cancer,  282 

Coley's  for  sarcoma,  274 
Sex  and  cancer,  18,  19,  24,  225 
Sexual  powers,  waning  of,  and  cancer, 

157 
Shanghai,  cancer  in,  37 
Sherman,  composition  of  human  body, 

201 
Sherrington    and    Copeman,    waning 

sexual  power  and  cancer,  157 
Shrinkage  of  nuclei  in  cancer,  81 
Sick,  lactic  acid  in  stomach  cancer,  131 
Sigmoid  cancer  of,  46 
Sittenfeld,  .-c-ray  in  cancer,  247 
Skill  of  operator  affecting  statistics, 

229 
Skin,  epithelioma  of,  42,  370 

diagnosis  of,  89 
Slavery  times,  absence  from  cancer  in, 

226 
Sleep  and  cancer,  31,  313 
Smith,  E.  V.,  cancer  in  plants,  14 
Soegaard,  cancer  in  Scandanavia,  217 
Soft  palate,  cancer  of  the,  392,  400 


Solids  in  urine,  relation  to  body  weight, 
14S 
total,  in  urine  of  cancer,  147 
Solomon  and  Saxl,  unoxidized  sulphur 

in  cancer  urine,  132 
Sophistication  versus  civilization,  180 
Soup    from    water    used    in    cooking 
vegetables,  215 
vegetable  extract,  in  cancer,  309 
Spain,  meat  eating  in,  208 
Special  immunity  in  cancer,  191 
susceptibility  to  cancer,  191 
Specific  gravity  of  blood  in  cancer,  129 
Spindle-cell  sarcoma,  61,  62 
Spino-cellular  epithelioma,  42,  43 
Spontaneous  regression  of  cancer,  71, 

121,  335 
Sprengel,  duration  of  life  in  untreated 

cancer,  106 
Stacy,     Mayo,     radium     therapy    in 

cancer,  254 
Stage  of  disease  affecting  results  of 

operation,  228 
Stagnant  colon  and  cancer,  318 
Stammler's  reaction  in  cancer,  76 
States  of  the  U.  S.,  cancer  in,  23 
Statistics,  objection  to,  17 

reliability  of,  elements  affecting, 
229 
Steiner,  cancer  of  the  lip,  232 
Stevens,  #-ray  therapy  of  cancer,  250 
Stomach  and  liver  deaths  from  cancer 
in  United  States,  225 
cancer  of,  diagnosis  of,  92 
mortality  of,  no 
prognosis  of,  no 
results  of  operation,  no 
Stout  people  and  cancer,  134,  152 
Strobel,  chemical  extirpation  of  breast 

cancer,  386 
Stroma  of  carcinoma,  67,  173 

of  sarcoma,  61,  173 
Structures  affected  by  carcinoma,  174 

by  sarcoma,  174 
Substances  inhibiting  cell  growth,  199 
Sulphur,  unoxidized  in  urine  of  cancer, 
132, 151 


INDEX 


455 


Sunlight  and  cancer,  313 
Supra-renal  cancer,  420 
Surgery,  aims  of  in  cancer,  112 

glamor  of,  obscuring  medical  con- 
sideration, 164 
in  cancer,  433 

of  cancer,  statistics  of,  222,  228 
Susceptibility  and  cancer,  189 

of  certain  organs  to  cancer,  194 
Sweat  glands,  misplaced,  and  cancer, 

187 
Sweet,    Corson,    White,    and    Saxon, 
effect  of  diet  on  experimental 
cancer,  214 
Systemic  condition  the  basic  factor  in 
cancer,  300 
derangement  in  cancer,  115 


Table  of  cases  observed,  369 
Taste   gratified   versus  appetite  satis- 
fied, 203 
Tea  and  cancer,  210 

consumption  of  in  England,  210 
Technique  of  chemical  extirpation  of 
breast  cancer,  387 

of  using  thorium  paste,  375 
Teratoma,  175,  176,  186 
Testicles,   internal   secretion   of,   and 

cancer,  156 
Tests  of  theories  by  treatment,  334 
Thermo  therapy  in  cancer,  437 
Thigh,  cancer  of  the,  424 
Thompson,  consumption  of  coffee,  210 

consumption  of  tea,  210 
Thoracic  duct  invaded  by  cancer,  119 
Thorium     paste     in     cutaneous    epi- 
thelioma, 374 
Thrombin  tissue  and  cancer,  288 
Thyroid  extract  in  cancer,  326,  327 

gland  and  cancer,  155,  156 

in  cancer,  295 
Tobacco  and  cancer,  218 
Tokio,  cancer  in,  37 
Tongue,  cancer  of,  364,  392,  393 
prognosis  of,  109 


Tonsil,  cancer  of,  365,  400 
diagnosis  of,  90,  91 
Torek,  cancer  of  the  oesophagus,  239 
Toronto,  cancer  in,  39 
Total  deaths  from  cancer  in   United 
States,  16,  222 
solids  of  urine  in  cancer,  147 
Toxic  nature  of  cancer  extract,  79 
sera,  action  of  in  cancer,  278 
Toxin  therapy  for  cancer,  273 
Trauma  and  cancer,  197 
Traumatism  in  breast  cancer,  101 
Treatment,  local,  of  cancer,  327-331 

medical,  334 
Trophoblastic   hypothesis    of    cancer, 

186 
True  cancer,  370 
Truth  of  theories  proved  by  results, 

334 
Tryptophan  in  tumors,  72 
Tuberculosis  and  cancer,  6,  15,  29,  40, 

165 
mortality    reduced    by    medical 
treatment,  301 
Tubular  epithelioma,  43 
Tumor  cells,  composition  of,  81 
ferments,  73 

growth,  intoxication  from,  126 
mesoblastic,  sarcoma  a  cancerous 

form  of,  174,  426 
proteins,  constitution  of,  71 
Tumors  benign,  171 
Type  of  persons  with  cancer,  324 


U 


Ulcer  of  rectum,  47 

Ultimate    results    of    operations    on 

cancer,  239 
United  States,  cancer  in,  16,  207 
deaths  from  cancer  in,  222 
increase  of  cancer  deaths  in,  222 
meat  eating  in,  207 
Unoxidized  sulphur  in  urine  of  cancer, 

132 
Unsatisfactory  results  with  radium  in 
cancer,  243 


456 


IXDEX 


Untreated  cancer,  235 
Aebli  on,  106 
Engleman,  on,  236 
Urbanization  and  cancer,  28,  220 
Urea  diminished  in  cancer  urine,  151 
Urinary  bladder,  cancer  of,  52 
diagnosis  of,  95 
duration  of,  112 
prognosis  of,  112 
Urine,  acidity  of,  relation  to  acidosis, 
149 
changes  in,  in  cancer,  131,  146 
imperfect  in  cancer,  320 
in  cancer,  amino-acids  increased 
in,  151 
chlorides  diminished  in,  151 
phosphates  diminished  in,  151 
sulphur  changed  in,  151 
indicating  character  of  blood,  147 
solids    of,    in    relation    to    body 

weight,  148 
volumetric  analysis  of,  147 
Urobilin  increased  in  cancer  urine,  150 
Uruguay,  cancer  in,  38 
Uterine  cancer,  results  of  cautery  in, 

235 
Uterus,  cancer  of,  55,  348-350,  358, 
389 
prognosis  of,  100 
results  of  operation,  108,  235 
deaths  from  cancer  of,  in  United 
States,  225 
Uvula,  cancer  of,  diagnosis  of,  91,  95 


Vaccino-therapy  for  cancer,  273 
Value  of  operations  in  cancer,  230 
Van  der  Velden,  absence   of  hydro- 
chloric acid  in  stomach  can- 
cer, 130 
Varied  medication  often  necessary  in 

cancer,  316,  321,  325 
Varying  deaths  from  cancer  in  States 

of  the  Union,  23 
Vater,  ampulla,  cancer  of,  50 


Vaughan,    J.    \\\,   anaphylactic   sen- 
sibility and  cancer,  75 

Vegetable  extract  soup  in  cancer,  309 
kingdom,  cancer  in,  14 
products,  raw,  in  cancer,  311 

Vegetables,  cooking  water  from,  used 
for  soup,  215 
proteid  in,  209 

Venezuela,  cancer  in,  39 

Venous  system  in  spread  of  cancer, 

"5 
Vesical  calculi  and  cancer,  52 
Vidal,  action  of  toxic  sera  in  cancer, 

27S 
cytolytic  serum  for  cancer,  280 
Virchow,  leucytosis  in  cancer,  129 
Vitamines  and  cancer,  310 
Voit,  Carl,  principles  of  diet,  204 
Volumetric  analysis  of  urine,  147 


W 


Walshe,  constitutional  nature  of  can- 
cer, 162 

Warren,  axillary  adenopathy  in  breast 
cancer,  102 

Warts  and  cancer,  173 

Wassermann  reaction  in  cancer,  75 

Watson,  Chalmers,  cell  structure 
altered  by  meat  diet,  206 

Wealth  and  cancer,  220 

Weight,  body,  in  relation  to  solids  in 
urine,  148 

Weir,  Dr.  R.  J.,  value  of  operations  on 
cancer,  230 

Weiss,  M.,  unoxidized  sulphur  in 
cancer  urine,  132 

Well-to-do  persons  and  cancer,  220 

Wertheim,  cancer  of  the  uterus,  235 

Whitman,  mutation  theory  of  cancer, 

157 
White  men's  diseases,  177,  183 
Williams,  H.  S.,  autolysin  for  cancer, 

284 
the  proteomorphic  theory,  288 
Williams,  W.  Roger,  agamogenesis  in 

cancer,  12 


INDEX 


457 


Williams,    W.    Roger,    constitutional 
nature  of  cancer,  138 
tubercle  and  cancer,  15,  40 
Woglom,  cachexia  in  cancer,  133 
Wolf,  Jacob,  statistics  of  cancer,  16, 

35 
Wolff,  protein  distribution  in  cancer, 

7i 
Wolter,  B.,  bio-chemistry  of  cancerous 

liver,  72 
Wood,  F.  C,  on  organ  immunity  to 

cancer,  194 
cachexia  in  cancer,  134 
Wound  healing,  absence  of  cancer  in, 

170,  197 


X 

Xanthin  and  cancer,  218 

bases  increased  in  cancer  urine, 

151 
X-ray  and  radium  in  cancer,  242 
as  local  measures,  434 
checking  metastases,  123 
in  cutaneous  epithelioma,  374 
in  metastases,  246 


Young  and  Frontz,  radium  therapy  in 

cancer,  255 
Young  persons  and  cancer,  194 


B37?. 


